Module 5: Understanding Health Policy Processes: Previous page | 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23

Annex 5b: Sector-Wide Approaches in Disrupted Health Sectors

Table of contents Contents Introduction The policy making environment Reviewing stated policies Matching stated policies to field realities Policy contents and allocative patterns Features of strong policy proposals Sustainability of chosen policies Looking at some concrete examples of policy implementation Actors: roles, perceptions, agendas Government (central and peripheral) Rebel groups Transitional (UN) authorities, UN agencies Development banks Donors The European Humanitarian Aid Office (ECHO) Non-Governmental Organisations (NGOs) New actors in the humanitarian field, Professional associations Understanding Coordination Recommended Reading References Annex 5a: Establishing a Policy Intelligence Unit Annex 5b: Sector-Wide Approaches in Disrupted Health Sectors

Over the last years, the interest aroused by sector-wide approaches (SWAps) as a way to rationalise external assistance and to provide coherence to sector operations, has brought the concept into the policy agenda of disrupted health sectors, particularly as they move from crisis to recovery. Donor agencies attracted by this approach have started considering it as potentially appropriate to disrupted contexts. Thus, the rebuilding of the East-Timor health sector has been explicitly seen by participants as inspired to the SWAp model. Also, a SWAp has been suggested for Afghanistan, although in this country it seems a very distant prospect.

SWAps have been defined in many ways, but usually include a number of key features, namely:

• A comprehensive sector policy, endorsed by most or all participants
• An expenditure programme, capturing most or all significant contributions
• Government leadership
• Reliance on government procedures
• The participation of all significant actors and their willingness to accept compromise, by relinquishing some of their traditional approaches (which, for some donors, implies flexibility and autonomy from central bureaucracies)
• A medium-long term timeframe of implementation
• Common approaches across the sector.

In extremely fragmented contexts, affected by severe resource scarcity and dramatic inefficiencies, the SWAp promises of rational and comprehensive programming maintain an obvious appeal. Translating these ideals into practice remains a tremendous challenge. Some of the hurdles to be found on the way towards introducing a SWAp in a disrupted health sector stand out quite clearly:

• The policy framework can be missing or being developed under pressure, sometimes borrowed from international models. The debate may remain within narrow circles. Crippled institutional memory jeopardises policy formulation. Political grievances and contested situations may rule out ‘rational’ policy discussions.
• The government leadership of the policy formulation process may be inadequate or absent, because of capacity constraints, limited power, contested legitimacy, unpreparedness of newly-appointed government officials, pressing competing tasks.
• The proliferation of private (for-profit and not-for-profit) actors, pursuing their own multiple goals, always difficult to accommodate to a shared policy framework.
• The information basis needed by a rational programming approach, such as that predicated under the SWAp, can be dramatically deficient. To forecast the future fiscal position of new states or that of governments emerging from protracted crises can be impossible. Without a resource hard constraint, unrealistic plans, driven by health needs or political calculations, are almost the rule.
• The long negotiation times typical of SWAps in normal sectors are at odds with the fast–evolving features of transitional contexts. Hard-pressed actors must take decisions without waiting for the SWAp process to deliver its products.
• Absorptive capacity is usually low in the public sector, as well as among private (for-profit and not-for-profit) operators. Crucial elements for the success of a SWAps, such as a regulatory body or auditing firms, can be absent or crippled. In extreme cases, as in Afghanistan, even commercial banks and the state budget were not in place.
• Relief agencies and NGOs, usually not conversant with, nor attracted by SWAps, may dominate the health sector, with large donors preferring to remain in the backstage. The risk adversity of donors is usually high in transitional contexts, where the political outcome is still unclear. And the undecided status of some authorities emerging from crisis may impede donor governments to deal directly with them.
• Donor goals can diverge substantially in a situation they may perceive as a clean slate. Dominant agencies compete for influence. Hence, donors may be reluctant to negotiate or to compromise. Unrestrained by the recipient government, aggressive agencies can pursue their agendas in isolation, justifying their stance with emergency or absorption concerns.

There is no doubt that the arguments militating against the pursuit of a SWAp in a disrupted context are powerful. To date, the only concrete adoption of a limited-scope SWAp has taken place in the unique settings of East Timor, a new small country having experienced a short, intense crisis, and placed under an interim UN administration. The applicability of that experience to other contexts remains to be seen.

In any case, the approaches adopted in a transitional context pave the grounds for future structural developments or conversely hinder them. If a sector-wide approach is premature in most transitional contexts, sector-wide thinking is not. In this sense, players might consider several initiatives bearing the potential (in the long term and once properly integrated in a consistent framework) of fostering a climate favourable to a SWAp. Additionally, they are attractive on their own, due to the systemic efficiency gains they may provide and the rationalisation they may introduce in the respective fields. For instance:

• to encourage sector-wide analysis, including the establishment of documentation centres and intelligence units, and the maintaining of dissemination channels. Standardising data collection may contribute to improved sector-wide analysis
• to establish sector-wide supply systems, such as drug purchasing and distribution, vehicle maintenance, etc.
• to agree upon a common salary scale for national cadres hired by NGOs and aid agencies (but beware, this process can take a long time, see True Story Nr 7)
• to adopt standard layouts for health facilities to be built or rehabilitated
• to develop joint training instruments, such as job descriptions, accreditations, course designs, training materials
• to explore the feasibility of introducing joint financing instruments for specific sub-sector areas.

Committed players may take advantage of the opportunities offered by transitional situations and explore these options in a long-term development perspective. The chances of success increase when the issues to be tackled by sector-wide initiatives truly concern most actors. Addressing concrete problems may overcome the frustration that usually connotes much coordination work and counter the vagueness of so many coordination events.

Effective aid management instruments can cultivate a collaborative culture and encourage progress to an extent unforeseen during the protracted crisis. At the start of any initiative, participation may be limited to few risk-taking players, willing or able to test the waters of novel approaches. Usually, only some of the launched initiatives register progress, and only when pushed by sustained efforts. These are likely to be joined later by more cautious partners.

To document these experiments and to assess their results is key to restore a measure of systemic memory and nurture capacity.

References

Foster M. Lessons of Experience from Sector-Wide Approaches in Health. WHO. 1999.

Module 5: Understanding Health Policy Processes: 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23

RELATED LINKS