L E S S O N S F RO M T H R E E A P P ROAC H E S TO I M P ROV E OUT C O M E S
Between fiscal 1997 and 2006, the World Bank approved 28 HNP projects supporting health SWAps in 22 countries.43 Thus, in the decade following the launch of the approach, about 13 percent of all approved HNP projects supported a SWAp. The World Bank project approvals came in two spurts—immediately after the 1997 meeting, followed by a two-year pause, and then more projects approved in fiscal years 2003–06 (figure 3.5). Two-thirds of the projects that supported health SWAps were in Sub-Saharan Africa. Support for health SWAps is mainly found in low-income countries, accounting for nearly a quarter of HNP projects approved in those countries, compared with only 6 percent of those in lower-middleincome countries, and none in upper-middleincome countries.44 In 71 percent of the projects, Bank resources were pooled with those of government and other donors.45 The assessment of the Bank’s support for health SWAps addresses three questions. First, were the benefits of the approach realized, in terms of better donor harmonization and coordination, reduced transaction costs, capacity building, and
400
8
376
371
7
350
6
300 260 250
244
5 4
200 165 140
150
3 2
100 50 0
Number of projects
The SWAp concept represented a fundamental change in the focus, relationship, and behavior of development partners and government—a reform in the relationship between government and development partners and among the partners. The specific health policies and programs supported by this approach depend on the content of the national sector strategy, which varies greatly across countries. World Bank and other donor support for a SWAp can be financed in a number of different ways—through parallel project-specific financing,41 pooled financing,42 general budget support to the finance ministry, or a combination of these.
Figure 3.5: After an Initial Spurt, Growth in World Bank Support for Health SWAps Resumed after 2002
Commitments (US$ millions)
action costs; more efficient use of development assistance; more reliable support for the health sector strategy; and greater sustainability of health programs. Ultimately, the approach, through its support of national health policies and programs, was to contribute to improvements in health sector performance and sustained improvements in people’s health.40
1
29 0
0
0
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Fiscal year approved Commitments
Number of projects
Source: Vaillancourt forthcoming.
so forth? Second, were the objectives Over the period fiscal of the health strategies supported by 1997–2006, the Bank government and development part- approved support for 28 ners achieved? Third, in what ways did health SWAps in 22 channeling support through a SWAp af- countries. fect the efficacy of the Bank’s support, including its ability to conduct policy dialogue? A desk-based portfolio review of all Bank-supported SWAps approved in fiscal 1997–2006, including 11 completed operations, and fieldwork in five countries (table 3.2) serve as a basis to answer these questions.
Benefits of the Approach The objectives, anticipated benefits, and specific mechanisms of the SWAp approach are not clearly articulated and often not discussed in the Bank’s project appraisal documents. These documents usually deal with the The objectives, substance of health programs and poli- anticipated benefits, and cies. There tend to be a lot of process specific mechanisms of indicators that implicitly convey what the SWAp approach are the objectives of anticipated benefits not clearly articulated were, and they are generally consistent and often are not with the SWAp features described in discussed in appraisal documents. the literature. 49