An overview of sector wide approaches (SWAps) in health: are they appropriate for aid-dependant Latin American countries?

Do experiences of SWAps in the health sector suggest that the approach should be adopted in Latin-America? This paper was written for the UK Department for International Development (DFID) by the DFID Health Systems Resource Centre (HSRC). It is aimed at policy makers, donor agency staff and health professionals working in countries where SWAps are or might be considered, and attempts to outline the main conceptual and practical issues involved in SWAp development.SWAps are first defined and explained, placing emphasis on their scope, their implications and the concerns of donors. Various country experiences are presented, followed by an analysis of the issues and barriers to implementation. The impact of SWAps, both on the health of poor people and in reducing poverty, is considered. Finally, the paper asks whether SWAps are appropriate for Latin-America.Findings from the experiences in other countries include the following:Most SWAps have concentrated on the role of the public sector, and not on the health sector as a whole.SWAps are regarded as incremental processes, building in scope as trust and experience develops over time.Achievements include: successfully developing plans and setting up systems to monitor performance; strengthening and expanding the role of governments and ministries of health; strengthening the structure of public budgets.Problems include: governmental capacity is strained due to the complex, lengthy process; difficulties getting governments and donors to agree to expenditure programs; joint funding remains relatively uncommon due to donor concerns over accountability; limited government resources; rigid donor procedures cause delays; the process is relatively non-participatory.The approach in itself is not inherently pro-poor, and its impact on the poor depends on policies contained and implemented in each country. Allocating more resources towards primary health care is very difficult to achieve.Public subsidies should be targeted to the poor, and their participation should be sought in service delivery.Under what circumstances would a health sector SWAp be beneficial to a Latin American country? What might be the scope of a SWAp in this context and how should it be developed?SWAps should be considered where: external aid either represents a sizeable percentage of the sector’s financing or where it is focused on key priority programmes; policy continuity has been a problem. In many Latin American countries, SWAps are an opportunity to define and maintain a focus for the sector, where inequalities in access and health status exist. Targeting of subsidies to the poor is critical; a SWAP can lead to reallocation of resources based on negotiation and needs assessment.Narrowing the scope of SWAps is important in the Latin American context. The implications should not be too overwhelming, too long term or simply impractical for the administration to consider.The key steps to building SWAps in Latin America should include: analysis of problems or policy areas as a joint effort by governments and donors from the beginning; defining a common strategy committing government and donors to a common understanding of objectives, strategies and processes; defining an implementation agenda; building capacity.This paper is also available in Spanish at http://www.healthsystemsrc.org/publications/Issues_papers/El_Enfoque_Sect.pdf