Exploring SWAp's contribution to the efficient allocation and use of resources in the health sector in Zambia
1 SWAp Secretariat, Department of Planning & Development, Ministry of Health Headquarters, Lusaka, Zambia.
2 Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
3 Health Economics Unit, Department of Public Health and Family Medicine, University of Cape Town, South Africa.
4 Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
* Corresponding author. SWAp Secretariat, Department of Planning & Development, Ministry of Health Headquarters, Ndeke House, P.O. Box 30205, Lusaka 10101, Zambia. Tel: +260 95 833 178. Email: cchansa{at}moh.gov.zm.
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Abstract |
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Zambia introduced a sector-wide approach (SWAp) in the health sector in 1993. The goal was to improve efficiency in the use of domestic funds and externally sourced development assistance by integrating these into a joint sectoral framework. Over a decade into its existence, however, the SWAp remains largely unevaluated. This study explores whether the envisaged improvements have been achieved by studying developments in administrative, technical and allocative efficiency in the Zambian health sector from 1990–2006.
A case study was conducted using interviews and analysis of secondary data. Respondents represented a cross-section of stakeholders in the Zambian health sector. Secondary data from 1990–2006 were collected for six indicators related to administrative, technical and allocative efficiency.
The results showed small improvements in administrative efficiency. Transaction costs still appeared to be high despite the introduction of the SWAp. Indicators for technical efficiency showed a drop in hospital bed utilization rates and government share of funding for drugs. As for allocative efficiency, budget execution did not improve with the SWAp, although there were large variations between both donors and year. Funding levels had apparently improved at district level but declined for hospitals. Finally, the SWAp had not succeeded in bringing all external assistance together under a common framework.
Despite strong commitment to implement the SWAp in Zambia, the envisaged efficiency improvements do not seem to have been attained. Possible explanations could be that the SWAp has not been fully developed or that not all parties have completely embraced it. SWAp is not ruled out as a coordination model, but the current setup in Zambia has not proved to be fully effective.
Key Words: SWAp, sector-wide approach, development assistance, efficiency, resource allocation, Zambia
KEY MESSAGES
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Introduction |
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A sector-wide approach (SWAp) is an increasingly common approach to development assistance in low-income countries, especially in the health sector (Sundewall and Sahlin-Andersson 2006
). It is a model of cooperation between recipient governments and all key stakeholders directly involved in the sector (WHO 2000) which is operationalized when: 'all significant funding for the sector supports a single sector policy and expenditure programme, under government leadership, adopting common approaches across the sector, and progressing towards relying on government procedures to disburse and account for all funds’ (Foster et al. 2000). In practice, a SWAp is jointly funded and coordinated in partnership with donors, emphasizing use of national systems.
The emergence of the health SWAp in the early 1990s was driven by the need to replace traditional project approaches and disease-specific vertical programmes after numerous concerns were raised about their ineffectiveness in fostering sustainable improvements in health. Commonly cited concerns were that such approaches are: narrow in scope; lead to fragmentation of the sector and high transaction costs; create risks for duplication of efforts; and weaken government capacity and local ownership (Cassels 1997; Jones 1997; WHO 1999; Foster 2000; Garner et al. 2000; IHSD 2003; Nokkala 2003; Walford 2003). The SWAp model was seen as an important approach to enhancing aid effectiveness, mostly through improved efficiency that would result from better aid coordination where the focus is put on developing and strengthening sector policies and institutional arrangements (WHO 1999; IHSD 2001).
Despite the increasing adoption of the SWAp model, its impact remains largely unexplored (Lake and Musumali 1999; Jeppsson and Okuonzi 2000; Kandimaa and Mattsson 2001; Frantz et al. 2004). Available literature, however, suggests that a well-functioning SWAp could foster good working relations between government and donor partners, and that this can significantly contribute to improving efficiency in the allocation and use of resources (Walford 2003). Experience also shows that the role of the Ministry of Health grew stronger when a SWAp was introduced in the Ugandan health sector (Jeppsson 2002). However, it has been argued that there is no evidence that a SWAp actually achieves the intended effects and that donors have embraced it only on the basis of its assumed improvements (Garner et al. 2000; Department for International Development 2001; Overseas Development Institute 2001; Hutton and Tanner 2004). It is also felt that the SWAp model could potentially make things worse if implemented haphazardly (Garner et al. 2000; Brown 2001; Hutton 2002).
In Zambia in the early 1990s, it was claimed that the health sector suffered from excessive centralization, weak partnerships and irregular availability of funds at almost all levels of the health system (Danish Ministry of Foreign Affairs 1994; Ministry of Health 1997). Donors were at that time mainly supporting multiple projects (Ministry of Health 1997; Kalumba and Musowe 1998). Though several donors were sceptical about the likely impact of the SWAp, Zambia became one of the first countries in the world to adopt the model, introducing it in the health sector in 1993 (Phiri 2003). The model was implemented with strong government commitment, and health reforms in Zambia at that time have been described as unprecedented both in terms of scope and speed of implementation (Lake and Musumali 1999). With the SWAp came the first ‘common district basket funding’ mechanism, i.e. pooling and channelling financial resources and delegating responsibility to district level (Danish Ministry of Foreign Affairs 1994; Phiri 2003). The aim was to bring all domestic and external funding together onto the government budget and improve efficiency through decentralized decision-making (Kalumba and Musowe 1997; Ministry of Health 1999; Ministry of Health 2003). Today the SWAp is the government's umbrella for all activities undertaken by both the government and the donors in the health sector under the framework set out in the national health strategic plan.
In recent years, the SWAp in Zambia has been challenged by an increasing amount of funds that are available only for disease-specific efforts, especially HIV/AIDS. Large initiatives and partnerships such as the Global Fund to fight Aids, Tuberculosis and Malaria and the President's Emergency Plan for Aids Relief (PEPFAR) have brought in significant funds since 2003. Much of the funding through disease-specific initiatives is not channelled through the common SWAp basket. In some cases, these initiatives also use separate reporting and accounting systems. Because of this, the discussion about project approaches and vertical programmes and their assumed inefficiencies has resurfaced.
The relatively long experience with the health SWAp makes Zambia an interesting case for studying the extent to which a country that adopts the model experiences any improvements in efficiency. This study therefore explores whether the envisaged improvements with the Zambian health sector SWAp have been achieved by examining developments in administrative, technical and allocative efficiency in the Zambian health sector from 1990–2006.
As the article sets out to assess the effects of the SWAp on different aspects of efficiency and not to evaluate the SWAp process as such, issues of governance and accountability, both important aspects of the sector-wide approach process, fall outside the scope of this paper.
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Methods |
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Data collection for this case study was conducted in Zambia over a 15-month period (November 2005 to February 2007) through key informant interviews, a group interview and secondary data. The interviewees were drawn from the Health Sector Advisory Committee which has broad sectoral membership, including the Ministry of Health, affiliated Statutory Boards, other ministries, bilateral and multilateral donors, global health initiatives, civil society and the private sector. Selection of the key informants was purposive, based on respondents’ (1) requisite expertise, (2) representation and (3) availability. Expertise was defined as having a minimum of 5 years working experience in the Zambian health sector. Representation meant ensuring wide coverage of stakeholders in the sector.
Eight categories of respondents were identified and representation was sought from each group. The categories were: bilateral donors (contributing to the basket), bilateral donors (financing projects and/or vertical programmes), multilateral/global donors, Ministry of Health officials (national and provincial levels), former employees of the Ministry of Health involved in the Zambian health reforms, researchers, civil society and the private sector. Interviewees were drawn from six of the nine provinces in Zambia.
In total 21 in-depth interviews were conducted. An interview guide1 was used; the questions were designed to assess the role of the SWAp in promoting administrative, technical and allocative efficiencies. The interviews lasted on average 1 hour and were conducted by the first author at the respondents' places of work. A group interview was also conducted with five financial specialists from five different provincial health offices. The group was engaged for 2.5 hours. The rationale was to establish a critical appraisal of the SWAp model and working arrangements through dialogue and debate.
Documents covering the period 1990–2006 were reviewed. This covered the time both before (1990–92) and after the health SWAp was implemented (1993–2006). The information was collected from two broad categories: (1) context of the health reforms and SWAp in Zambia, and (2) international literature on SWAps. Information was obtained from policy documents and legislation, research articles and technical documents, donor and government joint assessment reports, government databases, minutes/videos of SWAp-related meetings, and unpublished papers. Furthermore Pubmed, Medline, specialized websites and the search engines Google Scholar and Yahoo were used to search for literature.
Keywords we used when searching for information were ‘health SWAp’; ‘health sector-wide approach’; ‘development assistance’; and ‘aid coordination’. The search was narrowed down by applying words like ‘aid effectiveness’, ‘efficiency’, ‘resource allocation’ and ‘Zambia’. Research on health SWAps being relatively limited, only 132 documents relating to the subject matter were retrieved and reviewed.
Data analysis
The analysis followed a general inductive approach (Thomas 2003). Responses from the group and key informant interviews were recorded electronically and, through repeated listening and review of transcriptions, emerging themes were coded and related to the three themes—administrative, technical and allocative efficiency. The process of coding involved the identification of raw text segments with similar meaning units within and across the interviews, which were then categorized according to the three themes. Text segments were added to each category until all the relevant texts relating to the study objectives and themes were exhausted.
Operational definitions and measurement of variables
The contribution of the SWAp to improved efficiency was defined in relation to the goals of the Zambian health SWAp. The following indicators of administrative, allocative and technical efficiency were therefore developed.
Administrative efficiency: Improvements in administrative efficiency were defined as reduced transaction costs. The transaction costs of the SWAp were indirectly defined by the number of meetings held, time spent in meetings and number of donors using separate reporting and accounting systems.
Technical efficiency: Technical efficiency was measured by hospital bed occupancy rate at district level and expenditure on drugs. Hospital bed occupancy rate is one of the indicators that the Ministry of Health uses to assess the efficiency (in terms of productivity) of hospitals. It is defined as the percentage of total available beds occupied during a given time period.
Expenditure on salaries and other personal emoluments is the major cost driver of public health spending in low-income countries including Zambia. However, expenditure on drugs is also a significant expenditure item and availability of drugs is considered to be a proxy indicator of the quality of health care provided (Ugalde and Homedes 1998; Attridge and Preker 2005). Drugs used in public health facilities in Zambia are stipulated in the Basic Health Care Package and the Essential Drug List as recommended by WHO. Anti-retroviral drugs and vaccines are not included. Looking at the average in other countries in the region, expenditure on drugs as a percentage of total public spending on health has been estimated at 33% (Bennett et al. 1997). Thus, the study adopted a target of 33% based on empirical precedent.
Allocative efficiency: Allocative efficiency was defined as the degree of expenditure against budgets at different levels of the health care system (McPake and Kutzin 1997). It was assessed by looking at budgetary allocations by level of health care (central, province and district), actual disbursements (in relation to pledges) and timeliness/predictability of funds.
Table 1 provides a summary of the indicators and the data sources used.
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Results |
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Administrative efficiency
Time spent in meetings
A review of reports and minutes of the SWAp coordination meetings from 2002 to 2006 showed that a substantial amount of time is spent attending these meetings (Table 2). Respondents indicated that considerable time is spent organizing and staging SWAp-specific and other technical meetings. As part of the organization process, matters arising during the meetings have to be followed up and action taken, reports produced and circulated to all members in time for the next meeting.
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Number of donors using separate systems
A review of the number of donors pooling resources through the basket indicated that the number increased from five in 1993 (inception of the SWAp) to nine in 2003. This was out of a total of 15 donors that were participating fully in the SWAp meetings.2 In 2005 the number of donors who were members of the various SWAp committees and who were participating regularly in the SWAp meetings increased from 15 to 19, though the number of donors pooling resources dropped from nine in 2003 to seven at the start of 2006.
The donors who were not pooling resources had their own separate planning, budgeting and reporting formats. This was said to increase the administration workload of staff, especially the programme managers at lower levels who have to regularly submit reports to the Ministry of Health headquarters.
"The objective of a SWAp is to come up with a common report which will be accepted by all the players in the SWAp. If I submit one financial report it should be able to meet the needs of everyone. But what is happening now is that whichever donor sends money requests individual reports ... This is time consuming." (Provincial financial specialist)
Eight bilateral donors and one multilateral donor stated that there has been an increase of vertical programmes for specific diseases such as HIV/AIDS and that the use of separate systems has led to increased transaction costs and duplication of activities. A document review of support to HIV/AIDS related efforts found that there were several projects, and none were integrated into the SWAp. In 2004, one donor alone was operating over 24 sub-projects on HIV/AIDS at 128 sites covering 8 provinces. Another donor was funding 73 sub-projects for HIV/AIDS. As a comparison, before the SWAp in 1993, there were approximately 59 multilateral and bilateral projects in total covering a wide range of public health interventions, not only HIV/AIDS (Mtonga n.d.).
Technical efficiency
Hospital bed occupancy rate
In Zambia, the official target for the hospital bed occupancy rate is 80%. The reported average national bed occupancy rate was 71.2% in 1991 (before the introduction of the SWAp). This figure dropped to an average of 50% between 2001 and 2004, several years after the introduction of the SWAp (Ministry of Health 1992; Central Board of Health 2005). Over half of the key informants argued that productivity of hospitals had dropped due to inadequate support for cost items such as human resources, drugs and capital development during the SWAp implementation period.
A further review of documents showed that the districts and hospitals were failing to overcome the major barriers to improved service delivery due to the ceilings on expenditures for cost items such as drugs and capital development. For example, according to the SWAp guidelines on the use of basket funds, districts are allowed to use a maximum of 4% of their operational grants to buy drugs in emergency situations while hospitals are allowed a maximum of 10% (Ministry of Health 2000).
"There is need to have a full SWAp to address all the key areas especially human resources. Until we start supporting all critical areas, we will achieve nothing. A SWAp should support the full sector—it's supposed to be sector-wide. What we have is a district and hospital SWAp and further within that only a few cost items are addressed. It's not a full SWAp in terms of horizontal and vertical dimension. You need to go all the way if you expect to achieve more." (Bilateral donor)
Trends in drug financing
Table 3 shows the budgetary allocations for drugs (excluding ARVs) as a percentage of the total public health budget between 1990 and 2005. The analysis excludes funding from the Global Fund, World Bank, PEPFAR and other projects that buy bulk drugs for HIV/AIDS and tuberculosis. This is in order to make the data comparable over the time period.
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The data show that the share of government funds that is allocated to drugs has declined during the SWAp implementation period. The share of government funds to drugs declined from an average of 21.1% between 1990 and 1992 to 2.7% in 2005. Table 3 also shows that donor funding for drugs has been higher than government spending during the SWAp implementation period 1995 to 2005. The total share of funds allocated to drugs by both government and donors averaged 18.8% during the SWAp period (1995–2005).
During interviews, four bilateral donors (some contributing to the basket and others not) reiterated that drug financing has not been adequately prioritized even with the implementation of the SWAp.
"The SWAp supports all activities contained in annual action plans except for certain cost items like personal emoluments. Further, ceilings are put on how much money is to be spent on drugs, capital, allowances and so on." (Ministry of Health Official)
Allocative efficiency
Budgetary allocations by level of health care
According to the SWAp guidelines, a minimum of 60% of the total resources are supposed to be allocated to districts, 20% to major referral and specialized hospitals, 10% to the Ministry of Health headquarters and 10% to Statutory Boards and Training Institutions (Ministry of Health 1999; Ministry of Health 2000). The allocations to districts are meant to cover operational costs and exclude personnel emoluments and drugs which are procured centrally. An attempt was made to measure whether the government and the donors managed to fulfil this ambition. It was, however, only possible to obtain combined district and provincial budgetary allocations. Similarly, budgetary allocations to the Ministry of Health headquarters also include centralized procurements of drugs and personnel emoluments.
Documentation showed that between 1981 and 1992 (before the SWAp), an average of 31% of the total government health budget was allocated to provinces and districts compared with an average of 55% between 1996 and 2005 (Central Board of Health 1997–2005; Ministry of Health 1989–2007; Ministry of Health 2000).
For major referral and specialized hospitals, budgetary allocations declined from an average of 28% between 1981 and 1992 to 11% between 1996 and 2005. For statutory boards/training institutions, allocations dropped from an average of 12% between 1981 and 1992 to 8% between 2004 and 2005 (Central Board of Health 1997–2005; Ministry of Health 1989–2007; Ministry of Health 2000).
Budget performance and timing of disbursements
Table 4 shows donors’ actual releases against the budgets between 1990 and 1999. The data include all programmes and projects that were being run in the health sector at that time. The results show that the annual amounts budgeted by the donors increased by over 389% post-SWAp, from an average of US$14 million per year in the early 1990s to an average of US$68.4 million per year between 1995 and 2005.
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In terms of disbursements, between 1990 and 1992 (pre-SWAp) donors had released an average of 91% of the budgeted amounts. In 1995–2005 the average was 65%, but with large annual variations (36%-115%).
We further reviewed disbursements by the major contributors to the basket between 2000 and 2005 (Table 5). We found that on average 89% of the budgeted amounts were being released per year between 2000 and 2005 with variations between 68–207%. According to provincial financial specialists interviewed, basket funds were sent timely and were more predictable than government funding.
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Discussion |
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Zambia has a relatively long experience of working with a sector-wide approach. Yet, as our review shows, several donors were, and still are, outside the SWAp. Instead of moving towards harmonized support, the number of global, multilateral and bilateral projects supporting disease-specific efforts outside the SWAp has actually increased. It was estimated in 1998 that about 22% of donor support was directed through the SWAp (Daura and Mulikelela 1998
), while in 2005 this figure was 29%. A similar development has been seen in other countries which adopted a SWAp in the health sector. A review in 2003 showed that SWAp funds are growing but have not yet reached 50% of total donor resources in many countries (IHSD 2003).
Regarding administrative efficiency, transaction costs in the SWAp seem high when looking at the frequency and comprehensiveness of meetings and the large number of donors still using separate systems. In addition, there are also additional meetings for programmes and projects funded by resources which are not included in the SWAp. The different reporting systems used by donors are reportedly overburdening district-level staff. Even so, earlier findings documented an improvement as district-level managers had reported reductions in the duplication of management and logistics services (Lake and Musumali 1999). Lake and Musumali's study, however, was conducted barely 5 years into SWAp implementation, before the recent entry of global health initiatives in the Zambian health sector, and this could perhaps explain any difference.
The hospital bed occupancy rate in Zambia fell from 71.2% before the SWAp to around 50% after its implementation. According to Zere and others, a conventionally accepted level for bed occupancy is 80–85% (Zere et al. 2006). The Zambia Ministry of Health's national target for hospital bed occupancy is also set at 80%. Our findings further show that budgetary allocations to hospitals fell sharply between 1992 and 2005. The drop in occupancy and low productivity could be the result of a number of factors. One explanation could be the severe under-funding of hospitals (Nakamba et al. 2002). The under-funding was a result of the increased focus on funding for district-level care which was introduced with the SWAp. An additional explanation could be the critical shortage of core health workers (doctors, nurses and midwives) in the Zambian health sector (Ministry of Health 2003; Kombe et al. 2005).
One of the prime objectives of a SWAp is to build health sector stewardship under national leadership. Policy choices on allocation of resources for drugs do demonstrate, to a larger extent, the stewardship role of government. Our findings indicate that the government budget for drugs as a share of the total public health budget fell from 21% in the early 1990s to less than 3% in 2005. On the other hand, donor funding for drugs increased during the SWAp implementation period. Government and donor share of the budget spent on drugs has been fairly constant (at around 20%) during the SWAp implementation period (1995–2005). However, spending is lower than in other Sub-Saharan African countries where expenditures on drugs as a percentage of total public spending on health have been estimated to be around 33% (Bennett et al. 1997).
Poor targeting for drugs has had a negative impact on the availability of drugs. We established that drugs and medical supplies at hospitals and health centres throughout the country have been characterized as erratic. In most cases, districts and hospitals use operational grants earmarked for other activities to buy drugs from private suppliers in order to keep up with demand (Ministry of Health 2001).
The findings indicate small improvements in allocative efficiency. Funding for districts was in line with the SWAp guidelines for allocation of financial resources, but budgetary allocations to other levels of the health care system were not. In terms of budget execution, donors had increased their allocation to the sector during the SWAp. Actual releases, however, were lower after the inception of the SWAp and annual variations were large. Funds channelled through the basket seemed more predictable over time and their release was more timely.
Predictability of funding, commonly under a medium-term expenditure framework, has been highlighted as a core feature of the SWAp model (Cassels 1997; Walford 2003). The need for timely releases of funds has also been stressed (Foster 2000). The decline in releases in the 1997–99 period might be attributed to absorption problems, given the huge increments in the budget at that time. Low budgetary releases could also have been caused by partnership problems. In 1998 a few donors stopped providing support towards drug procurement due to questions over the award of a contract for storage and distribution of drugs (Ministry of Health 2002).
Methodological considerations
Evaluation research can be used to examine the effects of an intervention, and the potential causes of these effects (Övretveit 1998). Attributing effects directly to the SWAp is difficult, however, as it is not implemented in isolation. Boesen and Dietvorst (2007) provide an integrated conceptual framework for sector analysis which looks at the health sector as an open system of rules, norms, organizations, actors, processes and resources in a wider context commonly envisioned by all stakeholders to produce a set of outputs and to contribute to outcomes and wider impact. However, emphasis on the political economy and stakeholder aspects of SWAps makes their model more complex to use in reality, for formation of causal links and attribution of change. Further, the authors do not provide details on how to operationalize the model, enabling factors, definition of attributes/indicators and how overarching issues can be mainstreamed.
The SWAp has also been shown to sometimes have limited impact on already existing structures (Sundewall and Sahlin-Andersson 2006). Ideally, one would like to be able to measure effects of the SWAp in terms of impact on health outcomes, but finding a standard approach to determining such an impact has been deemed unlikely (Hutton and Tanner 2004). Walford has tried to establish a framework for evaluating SWAp impact. She defines impact as ‘better use of resources’ and links it to SWAp inputs such as government ownership and coordination of resources (Walford 2003). The problem with this and other attempts, however, is that the causal links and indicators used to determine change are unclear.
The use of multiple sources of evidence in this study served to increase the construct validity of the case presented (Yin 2003). However, the relevance and validity of the outcome indicators chosen to measure the SWAp's contribution to improvements in efficiency in this study could still be discussed. One could argue that to measure transaction costs, you cannot just measure the absolute transaction cost of the SWAp without comparing it with alternatives. Other measures of efficiency (such as levels of wastage, outpatient visits per staff, etc.) were not used given constraints in data availability, limitations in use and usefulness in terms of precision, validity, cost and interpretation. Furthermore, there is a risk of reporting errors in interviews due to the difficulty of recalling events and meetings held several years ago.
Thus, while there are limitations inherent in the variables chosen in this study and the difficulty of establishing causality, other approaches have similar or even more severe limitations. Ultimately, the analysis presented in this article does provide insights into the extent to which the SWAp's goals are being achieved.
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Conclusion |
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In this study, it was found that implementation of a SWAp in the health sector in Zambia has not contributed significantly to the attainment of administrative, technical and allocative efficiencies. There are a few indications pointing to improvements in administrative efficiency, even though there was limited data available. Technical efficiency decreased while allocative efficiency improved to some extent during the SWAp implementation period. This can either mean that the SWAp is not yet fully developed or that it has not been adequately implemented as not all partners‘ have completely embraced it. It is concluded that our findings do not rule out the SWAp as a coordination model, but its current setup in Zambia has not proved fully effective.
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Policy implications |
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Introducing a sector-wide approach in the health sector will not automatically lead to efficiency improvements. It seems that the SWAp can merely provide a framework for collaboration, but it will not necessarily create any significant change. In the case of Zambia, despite strong commitment, large amounts of resources are still channelled outside the government system.
In order to achieve a full SWAp, all actors (government and the developing partners) in aid-receiving countries must further harmonize implementation and reporting systems in order to reduce the administrative workload of ministries of health. Furthermore, all support should be coordinated and planned in relation to the goals set out in sectoral strategic plans. Doing this will not require a modification of the SWAp model itself; it is rather a task of developing systems for planning, funding, and monitoring and evaluation which all stakeholders can trust and adhere to.
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Acknowledgements |
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The study was conducted as part of a thesis for a Master of Public Health in Health Economics at the University of Cape Town. The scholarship for the training was financed by the Swedish International Development Cooperation Agency and The Ministry of Health, Zambia. The scholarship programme was coordinated by the Department of Economics, University of Zambia.
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Endnotes |
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1 The interview guide is available from the first author.
2 Pooling of funds and participating in the SWAp should be separated. When the SWAp was introduced, the idea was to invite all partners to the discussion, regardless of their individual funding arrangements. Thus, not all development partners who participate in the SWAp meeting are also pooling resources to the basket.
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References |
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Attridge JC, Preker A. Improving access to medicines in developing countries: application of new institutional economics to the analysis of manufacturing and distribution issues. (2005) HNP Discussion Paper: Washington, DC: World Bank.
Bannenberg W. Zambia drug supply budget line mission. (2004) A report prepared for the Ministry of Health on the options for the establishment, operation and sustenance of the drug supply fund.
Bennett S, Quick J, Velásquez G. Public-private roles in the pharmaceutical sector: implications for equitable access and rational drug use (1997) Geneva: World Health Organization. DAP Series No. 5.
Boesen N, Dietvorst D. SWAPs in motion. (2007) Sector wide approaches: from an aid delivery to a sector development perspective. Joint Learning Programme on Sector Wide Approaches and the Aid Delivery Methods Programme – EuropeAid.
Brown A. Integrating vertical health programmes into sector-wide approaches: experiences and lessons (2001) London: Institute for Health Sector Development, on behalf of the Swiss Agency for Development and Co-operation (SDC).
Cassels A. A guide to sector-wide approaches for health development – concepts, issues and working arrangements (1997) Geneva: World Health Organization.
Central Board of Health. Central Board of Health Databases 1997–2005. (1997–2005) Lusaka, Zambia.
Central Board of Health. Annual health statistical bulletin 2004: a presentation of selected indicators on disease burden and service delivery. (2005) Lusaka: Central Board of Health.
Danish Ministry of Foreign Affairs. Summary of consultations of the joint review and appraisal mission for the Danish support to the Zambian health sector reform process. (1994) Copenhagen: Danish Ministry of Foreign Affairs.
Daura M, Mulikelela D. Donor expenditures 1995–1998. In. Seshamani V, Mwikisa C, Ödegaard K, eds. (1998) Zambia's Health Reforms, Selected Papers 1995–2000: Lund: Swedish Institute for Health Economics and University of Zambia.
Department for International Development. Measuring health sector performance at country level. (2001) London: DFID. Report of a DFID workshop, 20–21 July 2001, organized by the Health Systems Resource Centre.
Foster M. (2000) What can we learn from experience with implementing sector-wide approaches? Working Paper 140: London: Overseas Development Institute.
Foster M, Brown A, Norton A, Naschold F. The status of sector-wide approaches. (2000) London: Overseas Development Institute.
Frantz B, Mpuku H, Wright J. Supporting the decentralized delivery of health services: USAID and the district basket in Zambia. (2004) Washington, DC: USAID.
Garner P, Flores W, Tang S. Sector-wide approaches in developing countries. The aid given must make the most impact. British Medical Journal (2000) 321:129–30.
Hutton G. Decentralisation and the sector-wide approach in the health sector. (2002) Basel: Swiss Tropical Institute. Key issue paper in the frame of the SDC Backstopping Mandate 2002 of the Social Development Division's Health Desk.
Hutton G, Tanner M. The sector-wide approach: a blessing for public health? Bulletin of the World Health Organization (2004) 82:893.[Web of Science][Medline]
IHSD. Orientation and training seminars for agency staff: sector-wide approaches for health in a changing environment. (2001) London: Institute for Health Sector Development. Seminar handbook. Inter-agency group on sector-wide approaches for health development.
IHSD. Mapping of sector-wide approaches in health (2003) London: Institute for Health Sector Development.
Jeppsson A. SWAp dynamics in a decentralized context: experiences from Uganda. Social Science and Medicine (2002) 55:2053–60.[CrossRef]
Jeppsson A, Okuonzi SA. Vertical or holistic decentralization of the health sector? Experiences from Zambia and Uganda. International Journal of Health Planning and Management (2000) 15:273–89.[CrossRef][Web of Science][Medline]
Jones S. The sector approach: promise and pitfall. In: Oxford Policy Management Review (1997) Oxford: Oxford Policy Management.
Kalumba K, Musowe V. Sustainable partnerships for health. (1997) Paper presented at a consultative meeting on sector support programmes in Kafue Gorge: Zambia.
Kalumba K, Musowe V. Effective coordination and use of donor funding in Zambia. In: Sustainable health care financing in Southern Africa—Allison B, Doherty J, Gilson L, et al, eds. (1998) Washington, DC: The World Bank.
Kandimaa A, Mattsson P. Sector programme support to the Zambian health sector 2002–2005. (2001) Stockholm: Swedish International Development Cooperation Agency. Assessment memorandum.
Kombe G, Galaty D, Mtonga V, Banda P. Human resource crisis in the Zambian health system: a call for urgent action (2005) Bethesda, MD: Partners for Health Reformplus project, Abt Associates Inc.
Lake S, Musumali C. Zambia: the role of aid management in sustaining visionary reform. Health Policy and Planning (1999) 14:254–63.
McPake B, Kutzin J. Methods for evaluating health system performance and the effects of reforms. (1997) Geneva: World Health Organization. Current Concerns: ARA paper no. 13.
Ministry of Health. Ministry of Health databases 1989–2007. (1989–2007) Lusaka: Ministry of Health, Zambia.
Ministry of Health. National health policies and strategies. (1992) Lusaka: Ministry of Health, Zambia.
Ministry of Health. Independent review of the Zambian health reforms: Volume 1 – Main report. (1997) Zambia: Lusaka: Ministry of Health.
Ministry of Health. Memorandum of understanding concerning the National Health Strategic Plan (2001–2005). (1999) Zambia: Lusaka: Ministry of Health.
Ministry of Health. Joint identification and formulation mission: a proposed health sector support investment programme (2001–2005), volumes 1 and 2. (2000a) Zambia: Lusaka: Ministry of Health.
Ministry of Health. National Health Strategic Plan 2001–2005. (2000b) Zambia: Lusaka: Ministry of Health.
Ministry of Health. Joint health (pre)appraisal report. (2001) Zambia: Lusaka: Ministry of Health.
Ministry of Health. Brief on the medical stores limited contract. (2002) Zambia: Lusaka: Ministry of Health.
Ministry of Health. Mid-term review of the National Health Strategic Plan 2001–2005. (2003) Zambia: Lusaka: Ministry of Health.
Mtonga BS (n.d.). Planning for and management of external aid for health in Zambia. Lusaka.
Nakamba PM, Hongoro C, McPake B, et al. Zambia case study. In: Health sector reforms: What about hospitals?—Eriksson P, Diwan V, Karlberg I, eds. (2002) Gothenburg: Nordic School of Public Health.
Nokkala M. Health sector programs and well-being: ensuring the poor can benefit from a sector-wide approach. (2003) Presentation at the WIDER Conference on Inequality, 30–31 May 2003: Poverty and Human Well-being, Helsinki.
Overseas Development Institute. An overview of the SWAp debate. ODI keysheets. (2001) London: Overseas Development Institute.
Övretveit J. Evaluating health interventions (1998) Buckingham: Open University Press.
Phiri FV. Decentralisation and the SWAp in the health sector in Zambia. (2003) Berlin: Learning Network on Program-Based Approaches (LENPA).
Sundewall J, Sahlin-Andersson K. Translations of health sector SWAps—A comparative study of health sector development cooperation in Uganda, Zambia and Bangladesh. Health Policy (2006) 76:277–87.[CrossRef][Web of Science][Medline]
Thomas DR. A general inductive approach for qualitative data analysis. (2003) Auckland: University of Auckland School of Population Health.
Ugalde A, Homedes N. Medicines and rural health services: an experiment in the Dominican Republic. In: The context of medicines in developing countries: studies in pharmaceutical anthropology—van der Geest S, Whyte SR, eds. (1988) Dordrecht: Kluwer. 57–80.
Walford V. Defining and evaluating SWAps (2003) London: Institute for Health Sector Development.
WHO. Lessons from experience from sector-wide approaches in health (1999) Geneva: World Health Organization.
WHO. World Health Report 2000: Health systems – improving performance (2000) Geneva: World Health Organization.
Yin R. Case study research design and methods (2003) Thousand Oaks, CA: Sage Publications.
Zere E, Mbeeli T, Shangula K, et al. Technical efficiency of district hospitals: evidence from Namibia using data envelopment analysis. Cost Effectiveness and Resource Allocation (2006) 4:5.[CrossRef]
Accepted for publication 18 April 2008.
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