Between Intent and Achievement in Sector-Wide Approaches: Staking a Claim for Reproductive Health

Abstract

Since 1995, sector-wide approaches (SWAps) to health development have significantly influenced health aid to developing countries. SWAps offer guidelines for new partnerships with international donors led by government, new relationships between donors and shared financing, development and implementation of agreed packages of health sector reforms. These structural and funding changes have significant implications for reproductive health. The early experience of SWAps suggests that the extent of donor commitment is constrained for administrative, philosophical and political reasons, with vertical programmes (including those relevant to reproductive health) protecting their ‘core’ business, and reproductive health, as an integrative concept, lacking strong advocates. Defining the sector in terms of government health systems focuses resources on building effective district health systems, but with uncertain outcomes for elements of reproductive health that depend on multi-sectoral strategies, e.g. safe motherhood. The context of the reforms remains a determining factor in their success, but despite savings available through increased efficiencies and coordinated services, the total per capita expenditure on health to ensure minimum clinical and public health services often remains beyond the budget available to least developed nations. Despite this, many of the elements of SWAps – government leadership, new donor relationships, better coordination, sectoral reform and service integration – offer the potential for more effective and efficient health services, including those for reproductive health.

Résumé

Depuis 1995, les approches sectorielles (sector-wide approaches ou SWAps) au développement de la santé influencent profondément l’aide sanitaire aux pays en développement. Elles proposent des directives pour de nouveaux partenariats avec des donateurs internationaux sous la direction du gouvernement, de nouvelles relations entre les donateurs et le financement commun, la création et l’application d’ensembles agréés de réformes du secteur de la santé. Ces changements structurels et financiers ont des conséquences sur la santé génésique. Les premières expériences avec les approches sectorielles indiquent que l’engagement des donateurs est limité par des facteurs administratifs, philosophiques et politiques, les programmes verticaux (notamment ceux qui intéressent la santé génésique) protègent leurs intérêts «centraux», et la santé génésique, comme concept intégratif, manque de défenseurs énergiques. La définition du secteur en termes de systèmes publics de santé centre les ressources sur la mise en place de systèmes de santé de district efficaces, mais avec des résultats incertains pour des éléments sanitaires qui dépendent de stratégies multisectorielles, p. ex. la maternité sans risque. Le contexte des réformes demeure un facteur déterminant de leur succès, et malgré les économies réalisées grâce à l’efficacité accrue et la coordination des services, les dépenses totales de santé par habitant pour garantir des services cliniques et de santé publique minimums demeurent souvent hors de portée des nations les moins avancées. Pourtant, beaucoup d’éléments des approches sectorielles – direction gouvernementale, nouvelles relations entre donateurs, meilleure coordination, réforme sectorielle et intégration des services – pourraient offrir des services de santé plus efficaces et efficients, notamment en santé génésique.

Resumen

Desde 1995, el Enfoque Sectoral (SWAp) ha tenido una influencia significativa sobre la ayuda para la salud destinada a los paı́ses en desarrollo. Dicho enfoque ofrece pautas para el establecimiento de nuevas alianzas con la cooperación internacional bajo el liderazgo gubernamental, y nuevas relaciones entre los donantes y el financiamiento, desarrollo e implementación compartida de paquetes convenidos de reformas del sector salud. Las experiencias tempranas con el Enfoque Sectoral sugieren que el compromiso de los donantes estárestringido por razones administrativas, filosóficas y polı́ticas, y que sus programas verticales protegen sus intereses principales, mientras que la salud reproductiva, como concepto integrante, carece de defensores fuertes. Al definir el sector en términos de los sistemas de salud pública, se enfocan los recursos en la construcción de sistemas de salud eficaces a nivel de distrito pero con resultados inciertos para los elementos de la salud reproductiva que dependen de estrategias multi-sectorales, tales como la maternidad sin riesgos. El contexto de las reformas sigue siendo un factor determinante para su éxito. Aunque una mayor eficiencia y la coordinación de servicios hayan resultado en ahorros, los presupuestos de las naciones menos desarrolladas frecuentemente no alcanzan cubrir el gasto total per cápita en salud que garantizarı́a los servicios clı́nicos y de salud pública mı́nimos. No obstante, muchos de los elementos del Enfoque Sectoral, tales como el liderazgo gubernamental, nuevas relaciones entre los donantes, mejor coordinación, reformas sectorales e integración de servicios, apuntan hacia servicios de salud – incluyendo los servicios de salud reproductiva – potencialmente más eficaces y eficientes.

Key Words:

• sector-wide approaches
• reproductive health policy and programmes
• health sector reforms

Metaphor is intrinsic to the way we conceptualise and define our experience, as Lakoff and Johnson [1] point out; it both interprets and determines our understanding of a concept. The metaphors that we use in debating sector-wide approaches (SWAps) are indicative of the paradox of SWAps: SWAps represent clearly defined territory, with constituent elements readily mapped out, but at the same time, they represent a process (at times uncertain) leading towards that territory.

The spatial metaphor is well established in the literature around SWAps for health sector development in developing countries. The term “sector-wide approach” itself defines both the scope and depth of the territory, as well as a mode of engaging it. SWAps promote continuing debate on integration of vertical programmes (those programmes focused around specific diseases or target groups with their own management and supervision structures) and horizontal programmes (those integrating a range of services with shared structures and management). They raise issues of centralisation and decentralisation of systems, and the extension of health coverage to the population as a whole. The much-used analogy for local control of the process – “putting the government in the driver’s seat” – takes the metaphor and extends it in terms of travel [2][3]. Peters and Chao [4] ask not only “What is it?” but “Where is it leading?”. Buse [5] also writes of the Bangladesh SWAp in terms of space and travel: a political horse needing training, a “tight grip on the reins”, “green pastures for development cowboys” and “corralling” of donors.

Cassels [6] makes it clear in A Guide to Sector-Wide Approaches for Health Development that SWAps are not a blueprint, but an approach. The working definition for SWAps focuses on the “intended direction of change, rather than the achievement” [7][8]. The concept is a guide, but not a “template for navigation through this largely uncharted territory” [9].

But the metaphors of space and travel also speak to concerns of power – of territory, ownership, direction and control. Any examination of the impact of SWAps on reproductive health needs to acknowledge the highly politicised environment in which these reforms are being played out [10][11]. To continue with the metaphor, “staking a claim” for reproductive health requires attention both to the ends – the reformed health system that is being developed – and the means – the processes by which this may be attained. Simplistic analyses, based on idealized projections, offer poor yields. This paper will attempt to focus on the factors influencing reproductive health services implicit in SWAps and build on evidence of returns to date.

Defining SWAps

The definitions of SWAps range from the prescriptive [2] (insisting on the participation of all main donors and including all expenditure within its brief, and using common implementation arrangements) to the more inclusive (involvement of one or more donors, most significant funding and progress towards use of government financial processes) [7], with the resultant slipperiness in definition resolved by acknowledging the intent rather than the achievement of the changes [11]. The definition offered by Brown et al [8] captures the evolving nature of the process. For them, a SWAp is achieved when:

“… 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.” [8]

Cassels’ definition [6], however, has the advantage of giving greater prominence to the relationships, context and goal of the approach, and will be used to explore the implications of SWAps for reproductive health:

“A Sector-Wide Approach to health development is a national partnership, led by national authorities, involving different arms of government, groups in civil society, and one or more donor agencies with the goal of achieving improvements in people’s health and contributing to national human development objectives in the context of a coherent sector … through a collaborative programme of work …” [6]

Defining reproductive health

The debates that have contributed to the evolution of SWAps mirror debates that challenged the narrow focus of population control and contributed to the emergence of reproductive health [12]:

“a comprehensive approach to women’s health and well-being, that includes fertility and infertility, contraception, abortion, childbearing, maternal morbidity and mortality, sexuality, sexually transmitted diseases, menstruation and menopause.” [13]

Both debates echo the ideological struggle between comprehensive and selective primary health care (PHC), with proponents of selective PHC arguing for cost-efficient disease interventions that are able to significantly reduce the burden of disease in the short term [14], while those advocating comprehensive PHC point out that sustainable health outcomes depend on a complex of social, economic and environmental changes, only achieved through community participation in multi-sectoral strategies [15][16].

Establishing a sustained partnership

The need for effective coordination in development assistance is self-evident in reviews of international aid. Buse and Walt [17] describe “an unruly mélange of external ideas and initiatives” that confronts health planners, and list eight coordination mechanisms employed by donors to rationalize project support. The shift from aid coordination to resource management, which is integral to the concept of SWAps, marks a radical development [18]. Making government ownership the sine qua non of SWAps [6] provides a new mechanism of control and discipline over donors through deference to national leadership and the constraints of peer–donor pressure [11][18].

The sector-wide approach also seeks to relocate the level and locus for collaboration between donors. While primary health care models addressed integration of programmes and services at the district level, the sector-wide approach pushes for integration at a central level, with pooling of financial resources and a shared development of policy and planning processes.

Many multilateral donors and non-governmental organizations (NGOs) have emerged in response to specific health needs, or they target particular diseases or groups. Whether they are international, national or local in their outreach and focus, the specific nature of these organizations may limit their incorporation into a sector-wide approach, because pooling of funds that have been given to NGOs for identified purposes is unlikely to be acceptable to the original donors or the NGOs themselves. Non-governmental organizations may be further marginalised from debate around sector-wide approaches because of the smaller scale of their operations, with multilateral and bilateral organisations tending to dominate. In Cambodia, UNFPA, given its status, is represented on the Coordinating Committee (COCOM) of the Ministry of Health, which has been deliberating on the implementation of sector-wide management (SWiM) – the local precursor to a SWAp [19][20]. In contrast, an agency like Population Services International [21], despite its high local profile in social marketing of condoms and oral contraceptives, has to depend on the NGO umbrella organisation MEDICAM to represent it – as do all other NGOs, local and international – in current COCOM discussions. Ironically, major donors – including key multilaterals and bilaterals – may continue to be represented in SWAp deliberations, even where they do not intend to contribute to the pooled resources [5].

Similarly, a number of bilateral donors are strongly associated with particular forms of development assistance, or have histories of association with particular programmes or regions. While these donors and programmes may make some contribution to the common resource pool, in most cases, coordination takes the form of participation in a matrix, with particular donors accepting responsibility for specific sub-sectors within the overall planning framework [17]. As a consequence, these mechanisms do not easily address some of the issues of equity of resource allocation across the sector.

In a sense, SWAps focus the process of integration at the negotiating table between donors and government. It requires a process of priority setting and collaboration that has not yet been successful at international level. While the integrated concept of reproductive health may have broad currency, the donors and agencies supporting the diverse elements of reproductive heath have limited interest in changing the resource inequities evident between them. Goodburn and Campbell [22], in advocating SWAps as a potential key to the reduction of maternal mortality, highlight this anomaly. The studies they quote suggest that almost half of development assistance in health is directed towards the broad category of reproductive health. Of this, however, the bulk contributes to fertility control, with an insignificant proportion committed to safe motherhood programmes. On the basis of this, they argue that:

“It may make better tactical sense for maternal health programmes to be linked with and tap into the greater funds available for health sector development, rather than to compete with a large, articulate constituency for family planning funds.” [22]

While improved maternal outcomes are a desirable consequence of health system reforms, this passive acceptance of vertical solutions for specific services makes the achievement of comprehensive reproductive health care much less likely. The inequity that was previously apparent in the mélange of uncoordinated projects [17] will continue, if donor agencies, while acknowledging the importance of a comprehensive reproductive health paradigm, seek to protect their own particular project interests.

Setting the sectoral boundaries

Sector-wide approaches are a recognition that increased coordination is imperative if more effective outcomes are to be achieved through development assistance than through project based aid [23]. SWAps take coordination mechanisms a step further than the existing patterns of geographical zoning, sub-sectoral specialization, agency coordination and financial and administrative harmonization [17]. By taking a sectoral approach, the SWAp extends a blanket claim over the whole of the health system, replacing the patchwork of donor-supported district and technical projects. It achieves this in two ways: firstly, by corralling all significant funding for the sector [8] into a single expenditure programme, and secondly, by the establishment of sectoral policies and strategies that demarcate priorities and determine resource allocation. That these two mechanisms can be considered radical changes underscores the limited extent to which Ministries of Health have had control over total health expenditure, and the absence of a coherent policy framework for health in many least developed countries.

In expanding its claim over the whole sector, however, the SWAp also marks its own limits at the sectoral boundary. While the partnership may include “different arms of government, [and] groups in civil society” [6] the focus of SWAps is on the development of government health services, with regulation of the private and traditional sectors a second priority. This represents a conscious departure from the multi-sectoral orientation of primary health care, and reflects a different understanding of the basis on which health improves [16]. While advocates of SWAps recognise the necessity for overall social, economic and political change, they define sectoral responsibilities narrowly, arguing that the health SWAp assumes “whole of government” reform, with capacity-building in other sectors occurring simultaneously. Concurrent reforms in each sector – education, agriculture, local government, finance, etc – will provide the basis for overall development at district level, and the appropriate environment for inter-sectoral collaborations [7].

The boundaries set within the reform process may limit the depth of the reforms as well as the breadth. As part of the health sector reforms in pre-SWAp Cambodia [20], the Ministry of Health, with the support of WHO, has introduced a Health Coverage Plan. This has been based on the two-tiered operational district, consisting of a district referral hospital servicing a referral network of 10–20 health centres [24]. Each health centre catchment area covers an aggregate population of 10,000 – serving several clustered rural communities [25]. Under these arrangements, to access services, whether contraception, skilled attendance for an uncomplicated delivery or treatment of sexually transmitted infections, local people must either travel to the health centres or the health centres must provide outreach services to them. Funding for outreach activities is limited, some areas are still considered insecure and health care providers tend to focus on the communities in their immediate vicinity. For more remote communities, their only recourse is to the expanding but unregulated private sector [26].

Those elements of reproductive health that are dependent on improved health service skills, technology and facilities (e.g. maternal mortality, abortion, childbearing, midwifery and obstetric services, and management of sexually transmitted infections) may be advantaged by the focus on health sector infrastructure [27][28]. With women’s groups, nutrition, informal education, community development and income generation activities defined out of the health sector’s area of responsibility, those services that rely heavily on intersectoral collaboration for their promotion (e.g. family planning, HIV prevention, education of women) may be compromised by diversion of management energies into the processes of intra-sectoral integration and reform.

Mapping out a collaborative programme of work

The impact of a SWAp on the different components of reproductive health care depends to some extent on the specific variables contributing to change and on the pre-existing infrastructure of the health system [29]. While SWAps technically provide the financial and administrative mechanisms to enable the reform process, they are effectively inseparable: SWAps are implemented with the implicit intention of enabling fundamental, sustained change in policy frameworks, workforce, administrative and institutional structures. Although varying country contexts mean no prescriptive “blueprint” is appropriate with SWAps, there is a commonality in outcomes for the “programmes of work” initiated as elements of health sector reform:

•	improving civil service performance through determining workforce needs, establishing clear job descriptions and evaluation, and rationalizing reporting relationships, linking improved salary and conditions to improved performance, and developing transparent, efficient financial and accounting systems;
•	decentralization and integration of health services through local government agencies or health districts, with local management;
•	improving the capacity of Ministries of Health through restructuring, human and financial resource management, policy and planning development, and setting priorities and selecting cost-effective interventions;
•	extending health financing options through the introduction of user fees, community finance and insurance systems;
•	introducing managed competition through the encouragement of a range of clinical care providers;
•	working with the private sector, including NGOs, to extend coverage, and regulating to ensure maintenance of standards [30].

The reform agenda complements the move towards reproductive health in its emphasis on integration and sustainable development [12]. The predictability of outcomes, however, is dependent on a range of variables, and is not consistent across all aspects of reproductive health. Goodburn and Campbell [22] argue strongly for the potential reduction in maternal mortality accruing from reforms that establish functioning district health systems, extend coverage and improve the overall quality of health services, citing progress in China, Sri Lanka and Malaysia. Their caveat on integration in reproductive health programmes is the potential loss of that strength of focus needed to secure improvements in maternity care. Similar concerns of loss of technical expertise, declining treatment and logistics systems, and rigor in supervision and management are common to most vertical programmes faced with the prospect of integration at district level [31][32][33]. Sustaining change in the critical hospital-based elements of this strategy also proves problematic in resource poor societies [34], or where professional attitudes to the delivery of obstetric care are poor [27].

Lush et al [29] point to the importance of context to the success of integration of reproductive health services, a lesson with broad applicability to health sector reforms. The historical evolution of a comprehensive primary health care system in South Africa facilitated the accommodation of HIV/STD and MCH/FP services at district level through the total integration of financial, human resource and logistical services. In contrast, a tendency to preserve distinct technical and management structures for these services in Ghana, Kenya and Zambia has meant little effective change in structures and services delivered. This has resulted in a significant qualitative difference between the comprehensive rhetoric and the persisting selective reality.

The differing interpretation of comprehensiveness within the rhetoric of SWAps and health sector reforms raises issues of equity for reproductive health, and places the strong political resolutions of the Cairo Conference at risk [12]. The focus of current reforms is strongly influenced by the World Bank’s re-definition of health in economic terms [35]. The focus on health coverage is based on a provider perspective, with service “packages” based on cost-effectiveness, as distinct from comprehensiveness. Reich [36] argues that the World Bank’s leadership in international health (and hence in the promotion of SWAps) has seen a shift in prioritization away from the maternal-child health nexus championed by UNICEF towards the economically productive adult. Selection of interventions is increasingly determined on the basis of cost per quality-adjusted life year (QALY) saved, with the necessary but resource-intensive aspects of reproductive health less likely to gain inclusion in basic clinical and public health services.

Standing [37] also draws attention to the vulnerability of the poor, and women in particular, in the context of health sector reforms. The risk of specific marginalized target groups – the young, the single, the socially and economically disadvantaged – not being addressed in integration of contraception, STD and HIV/AIDS services into mainstream services has been an issue of concern [38][39]. Access to contraceptives may be significantly enhanced through the promotion of managed competition and the more positive engagement of the private sector, though quality control of services, subsidy of the poor and sharing of client data to ensure overall coverage in immunisation or family planning are difficult to achieve. The dependence on the private sector to extend service coverage and the introduction of user fees have had negative equity implications. This has even been shown in situations where improved quality of care through appropriate diagnosis and treatment result in private health services that are more cost-efficient [40][41][42].

Securing the resource package

The “ideal” SWAp proposes the pooling of all available resources – donor and government – under local government control. In practice, however, only a limited proportion of the resources available in a SWAp are pooled. “Earmarked” funding may be “tabled” for management within the collaboration, eliminating some areas of duplication and ensuring broader coverage [8]. Early evidence is that the total budget available for health is increased, both in terms of donor contributions and national budget, and that further income generated by cost recovery, decreased transaction costs for government and donors and systemic efficiencies may increase available funding [43]. The approach to resource management has also shifted from the linear logic of project planning, with a broader package of resources able to be applied incrementally as stages of the reform are completed. The dilemma is that for the least developed countries, the total per capita expenditure falls well short of the minimum US$9 per capita needed to provide the minimum package of health services, and that the reproductive health services included in these packages are limited to contraception, HIV prevention and STD treatment, antenatal and postnatal care and uncomplicated attended delivery. With donor funding accounting for up to 85% of total available government expenditure, immediate issues of effective coverage take precedence over any consideration of sustainability [7].

It is in the light of this reality that priority setting becomes fraught. Donor leverage is linked strongly to financial contributions, though ironically, smaller donors may secure positions of influence as a result of a history of developed trust, or by direct channelling of funding through government processes [7][18]. Priority setting to date has largely been determined by donor rather than government agendas, and with limited “pooled” resources, identified funds for specific programmes are relatively well quarantined. As a result, family planning resources tend to be more than adequate, and issues of coordination seem to present the greatest problems. The potential to influence the determination of the SWAp policy process without exposure to the risks of resource pooling is an option taken up by several significant donors, providing independent leverage in negotiations with government. Buse notes the failure of key donors – including USAID, Asian Development Bank, UNICEF, WHO and UNFPA – to join the Bangladesh SWAp, and the list of justifications offered. His analysis is that donors were reluctant to expose themselves to the SWAp’s “dominance over other actors and over the development agenda” [5].

In terms of reproductive health, the need for strong advocates at the policy table will be critical to outcomes, but Goodburn and Campbell [22] have been unable to identify any donor – supported SWAp that has emphasized safe motherhood as an indicator condition or goal, with maternal mortality overlooked as an issue even where maternal health problems are significant. Reproductive health advocates need to target the major donors, placing the complex needs of reproductive health back on the international agenda, arguing for greater support for its component programmes, and promoting models for integration of reproductive health services into health sector reform processes.

Conclusion

It is still too early to evaluate the impact of SWAps, and the complexity of context, political environment, pre-existing systems and limited resources colour the interpretation of the resultant reforms. There are elements of the journey that are not re-traceable: the recognition of the need for government leadership, the changing dynamics between donors and government and between donors themselves, the emphasis on sectoral reform and the integration and rationalization of services. The constraining realities lie within the inadequate budget expenditure available to many developing countries, with the resultant unstable conflicts over the most effective deployment of limited resources. In the context of SWAps, reproductive health claims face internal tensions as well as competitive pressures externally. As Reich [44] observes in a related context, it is time to shift the metaphors. The irreconcilable “vertical” and “horizontal” can provide no resolution to the dilemmas of health service delivery. The current deficits in available expenditure make securing coverage for the sector unrealistic. What can be built on, in metaphorical terms, is a new understanding of the spatial – the development of “networks” – of fresh collaborations, shared vision, developing trust and enduring relationships that may emerge out of the process of SWAps.