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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

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Zambian Health SWAp revisited – has it made the intended effects?

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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

Isn’t Donor Collaboration Wonderful?



































Source: WHO: Mbewe

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



Case management



Skilled birth attendance

Drug Use


New born care


Safe and Supportive Environment

Health system


Source: WHO: Mbewe

Notable Developments 1

Notable Developments 2

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

Annual Consultative


Sector Advisory Group (SAG) Committee

Policy Committee Consultative Committee

Monitoring & Evaluation


Capital Technical Working Group

Health Care Financing Technical Working Group

Procurement Technical Working Group

Human Resources Technical Working Group

SWAp Joint Annual Reviews

  • Zambia has conducted 5 independent joint reviews between 1992 and 2006.

  • 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




Sector Dialogue & Communication

Day to Day Management of the SWAp Collaborative Process

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 (1997-1999) and Volatility due to Ex. Rates (2005-2007)

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

THE (in USD) / Capita (at exchange rate)


Minimum level of investment recommended by the Commission on Macroeconomics and Health (CMH)

Source: The World Bank. 2005. World Development Indicators. 2006.

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 (2005-2006)

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


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