Implementation of SWAP in Health Sector : Experiences Lessons ...

1. Implementation of SWAP in Health Sector : Experiences & Lessons Learnt Dr BR Marasini Programme Coordinator Nepal Health Sector Programme Ministry of Health & Population Paper Presented at Nepal Portfolio Performance Review, December 3-4, Kathmandu

3. Milestones in Implementation of sector wide policy in health sector Nepal Health Sector Programme- Implementation Plan (2004-2010)-August 2004 Signing of Joint Financing Arrangement (JFA) between GoN, DFID and The World Bank –March, 2005 Signing of JFA by AusAid in June 2009 as third partner to provide health sector budget

4. Letter of Intent Signatory & Non- Signatory* Partners in Health

5. International Health Partnership+ New global health initiative launched in September 2007 with an aim to support developing countries in achieving health sector MDGs through health system strengthening, supporting national health plans and donor coordination In first phase eight countries (now 13) selected for IHP+ & one of them is Nepal “Nepal Health Development Partnership Compact” signed in February 2009 by Ministry of Health & Population and eight health sector development partners and it further commits to strengthen the SWAP in health sector

6. IHP+ Signatory

7. Major coordination activities related to SWAP in health sector Every year two Joint Annual Reviews (JAR) are held one for annual work plan and budget and another for review of sector performance and till date nine JARs completed successful ‘Health sector development partners forum’ chaired by health secretary as agreed in statement of intent signed in 2004 & IHP+ national compact in 2009 All major issues are duly discussed in the above two forums

8. Health outcomes and progress towards health sector MDGs-1

9. Health outcomes and progress towards health sector MDGs-2

10. Post SWAP Financial Performance

11. Achievements-1 Improved health outcomes and increased capacity on financial expenditure led to availability of more funds and vice-versa Availability of pool fund in significant percentage and joint planning and programming through JAR helped to prepare more realistic and comprehensive health work plan & budget Increased ownership noted among programme managers saying that it is our budget, rather than the earlier practice of saying budget of agency ABC.

12. Achievements-2 Good performance in terms of health outcomes led to additional 50 million USD financing from the World Bank The government financial & procurement system is gradually improving as SWAP promotes national system Evidences show that there is gradual strengthening of health system

13. Achievements-3 As a result of increased funding from internal & external sources pro-poor schemes & fully subsidized maternity care schemes launched and it helped to increase the access of poor and pregnant women in health services Availability of more funds in health sector also helped to address the constitutional provision of basic health as a fundamental right of the citizens and as an effort to remove the financial barrier and reach to all citizens with a universally available essential health care package, free health care scheme launched and users fees removed from primary health care system

14. Achievements-4 SWAP implemented at district level with merging of many programme heads into one as “integrated district health programme” Involvement of civil society, academic sector (health) and non-state sector is increasing in every JAR (more than 150 participants attend each JAR) Signatory or not all budget received is included into SWAP framework The health service utilization is increasing and disparity is decreasing in many health programme

15. Challenges-1 Low and personalized understanding of SWAP Capacity of sector has remained low due to unstable bureaucracy with frequent changes of leadership at national and local level No policy difference between SWAP and non-SWAP sector by NPC & MoF specially in case of annual planning has created problems at times Provision of multiple foreign aid management agency outside MoF- such as Social Welfare Council, local bodies is affecting the issue of alignment and harmonization

16. Challenges-2 China and India are big partners in health sector with significant contribution, but still alignment and harmonization is a problem Information systems specially financial, procurement, vital registration, physical assets and human resource management is not efficient Policy on technical assistance and turn key projects in terms of SWAP is not clear

17. Challenges-3 Tendency to search the achievements by their contribution by some donors is making reporting system very challenging There is increasing disparity in some health programme specially maternal health In last 2-3 years there is a tendency to demand unusually high amount of budget with MOF & NPC and it has created problem on timely finalization of annual work plan & budget (AWPB) & has affected SWAP spirit and created confusion and disputes and it is desirable to form a planning committee chaired by health secretary with high level representation from MOF, NPC and key partners and after it finalizes the AWPB, no further discussions should be held at any level

18. Lessons learnt-1 Health sector SWAP has increased ownership, harmonization and aid alignment The capacity of health sector in context of managing big programme such as SWAP or health sector programme is gradually increasing The health outcomes in health sector are becoming much more effective and improving faster after the introduction of SWAP

19. Lessons learnt-2 It is necessary to upgrade the national systems such as financial management, audit of financial expenditures and information management After implementation of SWAP commitments and availability of funds for health sector nationally and internationally has increased MoF should take leadership to establish inter-agency linkage with other SWAPs such as education and LGCDP and try to coordinate & address the SWAP related common issues

20. Thank you for your kind attention