I M P ROV I N G E F F E C T I V E N E S S A N D OUT C O M E S F O R T H E P OO R I N H E A LT H , N UT R IT I O N , A N D P O P U L AT I O N
Figure 3.6: Neither Mortality nor Fertility Declined during the 10 Years of Ghana’s Health SWAp Second Health and Population Project 1991–97
200
Health Sector Support Program 1998–2002
Health Sector Support Program 2003–07
10 9 8
150
7 119 108
6.4
100
111
111
5
5.5 4.6
4.4
77 66
50
6
57
4.4
4
71
3
64
Total fertility rate
Deaths per 1,000 live births
155
2 1
0
0 1988
1993 Under 5
1998 IMR
2003
2006
the types of activities found in the programs of work of countries such as Ethiopia, Mauritania, Senegal, and Tanzania include: delivery of a basic package of essential health services; reorganization and decentralization of services; redefining the role of the central Ministry of Health; contracting with the nongovernmental sectors; hospital reform; new supply- and demand-side service delivery mechanisms; health financing; and costsharing. All of these are in addition to the challenging capacity building and reforms in development partner relationships inherent in a SWAp. Guidance for reasonable sequencing and implementation that would make such reforms feasible is often absent. The result is that not everything gets done, the higher-priority interventions are neglected, and outcomes are below expectations.
Fertility
Sources for 1988–2003: Ghana Demographic and Health Surveys. Sources for 2006: Multiple Indicator Cluster Survey for 2007 (for under 5 and infant mortality); Population Reference Bureau (for fertility). Note: The mortality rates are averaged over the five years preceding the Ghana Demographic and Health Surveys (GDHS). The fertility rates for GDHS 1988, 1993, and 1998 are averaged over the five years preceding the surveys, while the fertility rates for GDHS 2003 and the Multiple Indicator Cluster Survey for 2006 are averaged over the three years preceding the surveys.
Impact of the Approach on the Bank’s Effectiveness
Setting up a SWAp can divert time and energies from delivering on substance.
In the operations that IEG studied, the Bank has often been instrumental in getting other development partners to pool resources; the donors who pool generally have a seat at the table in the policy dialogue (Vaillancourt forthcoming). The Bank has played a crucial role in supporting national capacities and systems for financial management, procurement, and other fiduciary aspects of the SWAps within the health sector.
SWAPs often supported overly ambitious programs that exceeded the capacity of government to implement.
The Bank has not withdrawn from policy dialogue under the SWAp, but there is a risk that consensus decisions among development partners and government will inhibit strategic choices and the setting of priorities, areas in which the Bank has often provided valued support to improve the efficacy of health policy. The SWAp implies ceding leadership and decision making to government and reducing the bilateral relationship with government in favor of collaborative partnerships with development partners. But the partners collectively may not have the will to intervene. In Ghana, for example, the partners were unsuccessful in pressing the government to address duplication of services between the Ministry of Health and the Ghana Health Services, although inaction in
priority over results. In Bangladesh, despite the long history of working with a consortium of donors, there was disruption with the formal adoption of a SWAp. However, in Kyrgyz there was a longstanding and productive working relationship among experts in government and between government experts and the donors’ trust, and the SWAp formalized what was already happening. Beyond the short-run disruption, it is difficult to tell whether the improved coordination, ownership, and other reforms in foreign aid introduced by the SWAp have had any long-run impact on the quality or efficacy of health programs. This remains a hypothesis.
52
SWAps have often supported overly ambitious programs of work, involving many complex reforms and activities that exceed government implementation capacity. Examples of