programme building under swap: some experiences from tanzania technical co-operation in health in a...

Programme Building under SWAp:

Some experiences from Tanzania

Technical Co-operation in Health in a Changing Context

Sector Wide Approach

in Tanzania

Definition of SWAp

All significant funding for the sector supports a single sector policy and

expenditure programme, under government leadership, adopting common approaches across the sector, and progressing towards

relying on government procedures to disburse and account for all funds

Source:

WHO: Sector-Wide Approaches for Health Development – A Review of Experience

First steps toward SWAp and Basket Funding 1999

• GOT and donors agreed on a SWAP implementation plan for 1999 – 02

• Elaboration of a a collaborative framework

– Programme of Work (POW)

– Plan of Action (POA)

• Memorandum of Understanding

• Six main donors contribute to holding account for joint funding (basket)

March 1998

June 1999

October 1999

December 1999

Points of interest:

• Contributing to one sector is not as easy at is sounds when there is an interplay of reforms to contend with.

• In Tanzania the Health Sector Reform and the introduction of the SWAp has been strongly impacted upon by the parallel Local Government Reform process.

What does SWAp/Basket mean for the districts?

• Considerable augmentation of the annual budget (0,5$ per capita)

• Significant improvement of planning

• Districts can implement their plans because money is available

• Reporting, monitoring, auditing have become routine tools

• Progress in decentralisation

Monitoring of the SWAp Process

• Joint review of the sector by SWAp partners:

Rationale?– Sector-wide snapshot of progress– Avoid multiple assessment missions– Conclude with key agreements

If we would take this seriously, no individual appraisal for German TC would be needed

Problems encountered with reviews

• Suitability of large forum?• Insufficient debate, premature conclusions,

decisions made at the lowest level of consensus• Limitations of technical work• Limited linkage with other reforms/ Ministries• Competing missions (!) – despite everything.

Problems encountered with reviews (2)

• Tendency to review everything (later growing focus on priorities)

• Too many external consultants, available expertise in country not sufficiently used

• Mostly a snapshot which was backward-looking• Donor driven and dominated by Basket Partners• Little owned by GoT/MoH (absence of top

management from MoH)

Improvements:

• Small technical committee to do thorough preparation• Inclusive process (MOH, PORALG, Basket/non-

Basket partners, CSO)• More forward-looking, less judgemental• Discussion of forward budget / strategic planning• More focus on results (State of Health) and health

issues (HIV, malaria) rather than SWAp mechanics• Development of new Strategic Plan in Partnership

(not without its problems)

Way forward….

• Basket funding becoming out of “fashion”

• DFID (a main basketier) will withdraw from the basket and will assist the sector by budget support

Rationale of DFID

– MOH gets what the donors decide, not what it argues the case for: earmarked funding undermines integrity of GOT budget process

– GOT funds still largely used for “core” costs, Basket fund as an “extra” for discretionary items: encourages frivolous expenditure

– Encourages MOH to look to donors rather than MOF for budget justification, performance appraisal: externalises accountability of MOH

– Increase in basket total but fixed district basket => ever-increasing central funding: how much more can MOH effectively absorb? Do we undermine decentralisation?

Key questions?

Basket versus Budget support•What is our position?

•What is the position of the BMZ?

Programme Building:

Tanzanian German Programme to Support Health

(TGPSH)

First steps to build a German TC Programme 2001

Start of the process :Sector Strategy Paper for Tanzanian-German

Co-operation in the priority area of Health through a thorough process of consultation with German stakeholders (KfW, DED, DSE/InWent, CIM) in Tanzania and Germany, which is endorsed by the BMZ and after consultation agreed upon with the GoT (MoH & MoF)

Shared Goal and Objectives

• Shared Goal with Government of Tanzania and Development Partners :

„To improve the health and well-being of all Tanzanians with a focus on those at most risk and to encourage the health system to be more responsive to the needs of the people”

Points of interest (1):

Linking interventions at the micro-, meso- and macro-level:

• Support implementation at the district level

• Strengthen the Regional Administration (as facilitator of decentralisation and reform)

• Contribute to national strategies

Points of interest (2):

Co-operation with a whole series of partner institutions – Central level : MOH, PORALG, MOE, TACAIDS,

IPH..

– Regional level: Training institutions, ZTC, RAS, RHMT...)

– District level: District-Councils, CHSB, CHMT) Public and private health care providers, NGO

Harmonisation of the complementing instruments of German development co-

operation:

• Financial co-operation (KFW: investment programmes, contribution to „basket“)

• Technical Co-operation (GTZ,GDS, DSE/InWent, CIM)

Points of interest (3):

Points of interest (4):

And the other SWAp and basket partners….

• There are several mechanisms to coordinate the partners which means a lot of meetings and takes a lot of time……..Bi and Multilateral Health Forum, Basket Fund Committee.

What is the current state of the Programme Building Process in

Tanzania?

Current state (1)

• The TGPSH operates in 4 Regions and covers about 15% of the Tanzanian population

• The programme is structured according to 6 components

Components

1. District Health and Quality Management

2. Reproductive Health

3. HIV / AIDS

4. Health Financing

5. Public Private Partnership

And an overarching issue

6. Human Resources for Health

Current state (2)

• Sessions are organised in all four regions in order to familiarise them with the Programme

• Regions and Districts can request support where they see TGPSH overlaps with their needs

• Respective activities should be taken up in the District Health Plans

Ownership of TGPSH

• Thus when districts request TC from the TGPSH in accordance with their agenda then a shared responsibility for the outcome is taken.

Constraints (1)

become apparent when issues of cross- and multi-sectoral ramifications are considered

• Multisectoral approach to fight the AIDS pandemic

• Reproductive health is not a concern of the health services alone

• Decentralisation of health services needs the local government

Constraints (2)

Capacity gap• Districts are overwhelmed with HSR –

issues (planning, budgeting, reporting)• Regions and districts will probably have

absorption problems to take on board the innovative Programme components (AIDS- boards, CHF, Quality Management)

Lessons being learned along the way...

• What experiences do we have in terms of building/development of a health programme?

• What do we have to look out for?

Lessons learned... (1)

• Very time consuming process to develop SSP involving all German institutions locally and at HQ-level

• Only the high commitment of GTZ project staff for partnership avoided donor driven (German) strategy

Lessons learned… (2)

• Programme development for the technical cooperation needed new approaches to involve maximum involvement of stakeholders (both Tanzanian and German)

• Advocacy had to be done for various stakeholders: Participation of some stakeholders was lukewarm in the beginning.

• Several rounds of discussion needed to reach consensus with all stakeholders

Positive Points:

• Synergy between the different German institutions eg. InWent and GTZ viz. HRH

• German contribution in Health and HIV/AIDS more visible

• Best practice inputted into strategic developments in the health sector and in the fight against AIDS

• GTZ key player in donor constituency in health• GTZ Co-oordinator chairs DAC-HIV/AIDS

group

Thank you for your attention!