Documenting results of efforts to improve health aid effectiveness Case study: BENIN

1. Documentingresults of efforts to improve health aid effectivenessCase study: BENIN Geneva, 27-28 October 2011 Elisabeth PAUL Based on a report prepared by Christophe DOSSOUVI

2. Context • Low economic growth and budget execution rates • Positive evolution of ODA (22% of P.E.), but weak quality of data on executed external funding • Proportion of health in the budget has stagnated over the past 10 years; State budget allocation reduced in 2011 • External funding accounts for ¼ of health budget • Health sector coordination framework still not very well defined / organized; little effective fora for donor-MoH policy dialogue (2 meetings/year + annual performance review)  no real health SWAp • NHP = PNDS 2009-2018, PTD 2010-2012 • Benin joined IHP+ in 2009, signed national Compact in November 2010 with 5 donors – but some important pillars of the Compact were lacking: coordination, M&E and fiduciary frameworks not defined

3. Q1: To what extent have aid effectiveness principles been put into practice? • Donor coordination and joint reviews, but no real SWApbefore IHP+  progress is recent • Progress in ownership of national strategies at central level – but implementation problems • Leadership is lacking (governance problems) • Some alignment on national strategies: PNDS/PTD • Much less alignment with national public financing and procurement systems (not reliable) • Recent progress in harmonization: joint HSS platform (WHO, WB, GFATM, GAVI + BTC) >< yet, risk to weaken the more global Compact process • M&E / PNDS performance plan recently developed • Little progress in MfDR (OK theoretically but not in practice; PBF is starting on a large scale) and mutual accountability

4. Q2: Has this helped to improve results? Results1: Has aid effectiveness actually improved? • Growing external funding for health, but decrease in State budget allocations to health in 2011 + low execution rates • Predictability of aid is very limited (+ difficulty for the GoB to collect information) • IHP+ Compact & search for effectively implementing it  renewed impetus to collaboration between donors • Joint HSS platform  reduction in transaction costs + first step towards joint financing agreement in the health sector (no pooling but common PIU + procedures) • More coherent support to HSS and distribution of districts between donors

5. Q2: Has this helped to improve results? Results 2: Has the health system been strengthened? • Participative process  consensus over the PNDS/PTD; yet, still misgovernance • Various problems associated with financing (allocation / execution + underperforming PFM) • Good coverage of infrastructures • Public sector HRH coverage has deteriorated in recent years + regional disparities • Better organization of the drug/med.product sector • Still quality problems of data provided by NHIS; new M&E plan should drive improvements

6. Q2: Has this helped to improve results? Results 3: Have health services improved? • Performance still unsatisfactory against targets, yet some progress has been recorded in recent years, specifically MCH indicators which are at relatively high levels: • Sharp reduction in MMR (224  137, 2003-2008) • HIV/AIDS preval., pregnant women (2.2%1.7%, 2003-2007) • Rise in HF consultation rate (38%  46.8%, 2003-2010) • Stagnation of some indicators (ANC1 94% in 2010; ANC4 61% in 2006; assisted deliveries 80% since 2001) • Inadequate neonatal care • Overall: progress in outcomes, but not systematically linked to (weak) public-sector performance private sector has made an enormous contribution towards achieving the MDGs in Benin

7. Q3: Decisivefactors and constraints overcome Main factors contributing to achievement of results: • Coordination of donors (even if imperfect) • Participative preparation process of PNDS 2009-2018 • Annual sector performance reviews • Thematic working groups & coordination at national level • IHP+  new momentum to the sectoralapproach / MDGs • Search for ways to implement the Compact in practice, especially through the HSS platform  strengthened collaboration among a “core group” of donors • Progress at process level, that are expected to yield progress at results level

8. Q3: Decisivefactors and constraints overcome Main constraints: • Lack of MoH leadership + misgovernanceof the sector • Maladjustments in the sectoral coordination framework + problems with quality and analysis of data  have to date precluded ongoing and priority-focused policy dialogue  donorsoften had to take the initiative to get projects moving • MoH lost technical & financial support with WB/EC GBS • Heterogeneity of donors  no single voice towards MoH • IHP+ process itself constrained by: • Weak leadership and ownership of MoH (except DPP) • Nonexistence of a sectoral approach before Compact with a number of undefined basic components (fiduciary, coordination and M&E arrangements)  delayed implementation • HSS platform  reluctance of some other partners, and risk to weaken the more global Compact process • Recurrent strikes and insufficient resources at operational level

9. Conclusion and perspectives • IHP+ & Compact  undeniably acted as a catalyst for a sectoralapproach, giving substance to aid effect. principles • Yet, as certain basic components of the Compact were not defined when the document was signed, it has taken some time before being translated into practice • HSS platform initiated by donors: • First concrete step to harmonization (alignment seems not possible so far) • Possible nucleus for implementing the Compact if extended to the whole PNDS + all donors • To date, the results of putting aid effectiveness principles into practice are noticeable only at the process level, but promising outlook in terms of results provided improved MoH governance, relaunch of policy dialogue & HSS