Programme Building under SWAp: Some experiences from Tanzania

1. Technical Co-operation in Health in a Changing Context Programme Building under SWAp: Some experiences from Tanzania

2. Sector Wide Approach in Tanzania

3. 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

4. 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

5. 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.

6. 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

7. 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

8. 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.

9. 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)

10. 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)

11. 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

12. 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?

13. Key questions? Basket versus Budget support • What is our position? • What is the position of the BMZ?

14. Programme Building: Tanzanian German Programme to Support Health (TGPSH)

15. 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)

16. 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”

17. 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

18. 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

19. Harmonisation of the complementing instruments of German development co-operation: Points of interest (3): • Financial co-operation (KFW: investment programmes, contribution to „basket“) • Technical Co-operation (GTZ,GDS, DSE/InWent, CIM)

20. 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.

21. What is the current state of the Programme Building Process in Tanzania?

22. 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

23. 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

24. 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

25. 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.

26. 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

27. 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)

28. 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?

29. 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

30. 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

31. 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

32. Thank you for your attention!