Sector-Wide Approaches fail to improve health

30 Jun 2010
Africa Fighting Malaria
The World Bank and its partners are failing to improve health outcomes in sub-Saharan Africa using Sector-Wide Approaches (SWAPs), according to a report by Advocacy to Control TB Internationally (ACTION).

A SWAp approach involves coordinated funding by development agencies into a sector, rather than individual investment in specific projects. Funding for this form of assistance has grown massively over the past decade - increasing from $2 million in 1998 to $937 million in 2007, and exceeding funding for both TB and malaria-specific support in 2006.

Yet, despite millions of invested dollars, SWAps as currently implemented fail to effectively address alarming TB rates in sub-Saharan Africa, the report argues. Moreover, the report finds little evidence demonstrating that SWAps enable improvements in health outcomes overall.

The report notes a dearth of evidence demonstrating the impact of SWAps on health outcomes, both in a literature review of the subject, and a review of World Bank projects.

Further analysis suggests the current World Bank approach to SWAps is deeply flawed. The report cites overemphasis on process and lack of attention to results, failure to correctly monitor funding, lack of focus on priority issues, insufficient technical evaluation and weak monitoring of supported projects as key reasons for failure.

Interestingly, the report notes that countries with the greatest success of improving TB outcomes are those who "ring-fence" their TB programs and continue focused efforts to improve detection and treatment, often using alternative funding.

These findings are consistent with those of a major evaluation conducted by the World Bank Independent Evaluation Group, which found that "only 4 of the 11 completed projects supported by SWAps had satisfactory outcomes in achieving their relevant program objectives".

The report argues this failure of SWAps to achieve demonstrable improvements in public health represents a "potentially lethal breakdown" in the World Bank's development assistance programs.

It calls upon the World Bank to reduce its emphasis on process, and instead focus on measuring and improving health outcomes. This, it argues, can be achieved through the establishment of clear indicators and targets for focus diseases, rigorous monitoring and evaluation of projects, the implementation of a 'results-based' approach to funding and greater transparency on the part of the World Bank.

The report also notes that SWAps were only intended to be implemented in countries with strong financial accountability and the capacity to carry out and monitor effective programs. Currently, SWAps are being implemented in many countries lacking these capacities.

Donor agencies, the report contends, need to better assess risk, and should only provide funding on a large scale to SWAPs where evidence shows funds are achieving health gains. This, in turn, will encourage appropriate design and effective implementation of SWAps.

A SWAp is a means to an end, and not an end in itself, the report reminds readers. The World Bank and other development agencies need to closely examine whether SWAps are fulfilling their promise to improve public health. If not, the World Bank and its partners need to change the way SWAps are implemented so that they can measurably, consistently and effectively achieve this goal.

Click here to read the World Bank's response to the report.