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
results, successful reforms can be expanded more broadly. Evaluation of pilot reforms and rapid dissemination of results can also demonstrate to skeptics that the reforms are feasible, weakening political resistance. The lessons of USAID’s pilot reform activities in the Issyk-Kul region of the Kyrgyz Republic were fully incorporated into the design of the first Health Reform Project, and the demonstration effect of that region encouraged other regions to accelerate reforms. As discussed in chapter 2, however, the Bank’s record M&E are critical in health of ensuring that pilot and reform projreform projects. ects include rigorous evaluation is weak. To summarize, about a third of Bank projects support health reform objectives, mainly in middleincome countries. The share of projects with health reform objectives has been in decline. The outcomes of health reform projects and the Bank’s performance are lower than for other HNP projects. This is an area with a lot of risk—political and technical—but nevertheless highly relevant. Many lessons have been learned. Two of the most important of these, which should affect future performance, are the need to carefully assess the political risks beforehand—including the interests and incentives of key stakeholders—and to try to minimize complexity.
Sectorwide Approaches In 1995, the World Bank defined and promoted a new approach to lending to address chronic problems in implementing health projects. These problems included insufficient local ownership and commitment; the lack of any noticeable trickledown effect from some proj-ects; low sustainability of benefits after initial implementation; confusion and dissipation of effort caused by the The Sectorwide Approach, approaches supported by different or SWAp, was developed donors; excessive expatriate technical between 1995 and 1997; assistance personnel; the weakening of the Bank was a major government capacity by the proliferation proponent. of donor-financed project units; and unsatisfactory results from some adjustment operations in the allocation of public expenditure (Harrold and others 1995). The term sector investment program was coined, encompassing six principles of sound project development
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Box 3.6: Genesis of the Sectorwide Approach in Health: An International Consensus During the 1990s, the concept of a programwide approach was discussed at a forum on health sector reform chaired by WHO with the active participation of Ghana, Zambia, and other partners. This led to the first meeting of several countries and development partners to discuss the approach in 1997. Cohosted by the Danish Ministry of Foreign Affairs and the World Bank, the meeting coined the term “sectorwide approach” and reached a consensus on two follow-up actions: (a) to commission a SWAp guide for the health sector and (b) to create an InterAgency Group to foster learning and promotion of SWAps, with WHO as the chair and with the active participation of partners and developing countries. Source: Vaillancourt forthcoming.
that supported a “broad sector approach to lending.” A sector investment program had to be: • Sectorwide in scope, covering all current and capital expenditures • Based on a clear sector strategy and policy framework • Run by local stakeholders, including government, direct beneficiaries, and representatives of the private sector • Adopted and financed by all main donors • Based in common implementation arrangements among all financiers • Reliant on local capacity, rather than on technical assistance, for implementation. Two years later this approach was relabeled a “Sectorwide Approach,” or SWAp, at a meeting of donor agencies (box 3.6), but the principles remained the same.39 The anticipated benefits from the approach included: greater country ownership and leadership in managing health support; improved coordination and oversight of the technical and financial inputs of all partners; strengthened country capacities and systems for strategic sector management, fiduciary functions, and implementation arrangements; reduced trans-