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Sector-Wide Approaches for health: lessons from Samoa and the Solomon Islands

Joel Negin
Sydney School of Public Health and Menzies Centre for Health Policy, University of Sydney, Australia.

The Nossal Institute for Global Health

www.ni.unimelb.edu.au

KNOWLEDGE HUBS FOR HEALTH

Strengthening health systems through evidence in Asia and the Pacific

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ABOUT THIS SERIES

This Working Paper is produced by the Nossal Institute for Global Health at the University of Melbourne, Australia. The Australian Agency for International Development (AusAID) has established four Knowledge Hubs for health, each addressing different dimensions of the health system: Health Policy and Health Finance; Health Information Systems; Human Resources for Health; and Womens and Childrens Health. Based at the Nossal Institute, the Health Policy and Health Finance Knowledge Hub aims to support regional, national and international partners to develop effective evidence-informed policy making, particularly in the field of health finance and health systems. The Working Paper series is not a peer-reviewed journal; papers in this series are works-in-progress. The aim is to stimulate discussion and comment among policy makers and researchers. The Nossal Institute invites and encourages feedback. We would like to hear both where corrections are needed to published papers and where additional work would be useful. We also would like to hear suggestions for new papers or the investigation of any topics that health planners or policy makers would find helpful. To provide comment or get further information about the Working Paper series please contact; ni-info@ unimelb.edu.au with Working Papers as the subject. For updated Working Papers, the title page includes the date of the latest revision. Sector-wide approaches for health: lessons from Samoa and the Solomon Islands First draft March 2010 Corresponding author: Joel Negin Address: Sydney School of Public Health and Menzies Centre for Health Policy, University of Sydney, joel. negin@sydney.edu.au This Working Paper represents the views of its author and does not represent any official position of The University of Melbourne, AusAID or the Australian Government.

ACKNOWLEDGEMENTS
The author would like to thank a number of people who have provided assistance through the research and drafting of the paper: Erica Mayer for excellent research assistance, Anne Marie Thow for helping to frame the analysis, Alex Martiniuk for support on the Solomon Islands components of the paper and the staff of the Nossal Institute for their input and support. The author would also like to thank the interviewees who were gracious with their time and insight. Travel to the Solomon Islands was funded by Rotary Sydney Cove.

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THREE PAPERS ON SECTOR-WIDE APPROACHES IN THE PACIFIC REGION

This is the third of three working papers prepared by Joel Negin on issues related to Sector-Wide Approaches (SWAps) for health in the Pacific region, with examples drawn from Samoa and the Solomon Islands. The three papers are: PHF Knowledge Hub Working Paper No.2 March 2010, Sector-Wide Approaches for health: an H introduction to SWAps and their implementation in the Pacific region. PHF Knowledge Hub Working Paper No.3 March 2010, Sector-Wide Approaches for health: a comparative H study of experiences in Samoa and the Solomon Islands. PHF Knowledge Hub Working Paper No.4 March 2010, Sector-Wide Approaches for health: lessons from H Samoa and the Solomon Islands. The papers are closely related but address the issue of SWAps in the Pacific region from three different angles. The papers represent initial ideas and a preliminary assessment of the situation in the Pacific region and aim to encourage further discussion in the current debate on aid effectiveness. The increase in recent years in official development assistance (ODA) for health and the growth in the number of public and private actors within the sector internationally have given rise to a renewed concern about the effectiveness of aid delivery. The role of the SWAp as an effective mechanism in the delivery of ODA has been the subject of considerable discussion. As donors increase the volume of funds available for health development, set goals and identify targets for desired outcomes, the issue of how best to involve different actors at national and global levels is a challenge. During the last two decades a succession of different approaches has been evident internationally. Reviewing these experiences and drawing out the lessons learned has occupied researchers, both as participants in the process and as observers. Little has been documented, however, about SWAp processes as they have been applied in the Pacific region. Many of the Pacific Island Countries (PICs) are remote, have small populations with a low average age, are aiddependent and are facing increasing health problems. It is important, therefore, to understand more fully how the myriad of issues surrounding aid effectiveness are unfolding in the region. These three papers contribute to that understanding. The first reviewed some of the international literature on SWAps for health and their introduction in the Pacific region and raised preliminary ideas on the main issues that contribute to their effectiveness. The second paper reviewed the SWAp processes used in two countries, Samoa and the Solomon Islands. The third offers some preliminary thoughts about the SWAp process based on the lessons learned from the two previous papers.

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ii Sector-Wide Approaches for health: lessons from Samoa and the Solomon Islands

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INTRODUCTION
The Sector-Wide Approach (SWAp) emerged more than 20 years ago as a means for improving the effectiveness of aid delivery in health and other sectors (Cassels 1997). Fundamental to the process is the recognised need for increased coordination of donor funding and development programs and their harmonisation with recipient country national health objectives, a process led and owned by developing countries themselves. SWAps have increasingly been implemented across the Pacific over the past few years, yet there has been limited analysis of the process of SWAp development in the region (Gilson and Raphaely 2008). Using the health-sector SWAps recently established in Samoa and the Solomon Islands as case studies, this paper aims to: assess the two SWAps against key elements based on global experience; dentify lessons from these SWAps that can inform current debates in the region about aid effectiveness, i using the lens of the Pacific Aid Effectiveness Principles; nalyse policy development in the Pacific in terms of actors, power and influences; in particular, to a investigate international-to-national policy transfer and dynamics. The first paper in this series (see Negin 2010a) provided an overview of the emergence of SWAps globally and in the Pacific region. The second paper (see Negin 2010b) explored the development of health SWAps in Samoa and the Solomon Islands. This third paper builds on the frameworks and experiences outlined in the previous two papers and highlights the important lessons from the Samoan and Solomon Islands experiences. This paper draws methodologically on the earlier papers in a number of ways. The analytical framework for this paper is based both on the policy analysis approach (Walt and Gilson 1994) and the key elements of the SWAp process identified in the first paper. The evidence on which the analysis in this paper relies is taken from the document reviews and key informant interviews that were used as methods of data collection for the case studies of Samoa and the Solomon Islands. Interviews for the broader study were carried out through telephone and in-person interviews with representatives of government agencies, multilateral organisations, donor agencies, academic institutions and experienced health consultants. In total, 19 interviews were conducted both within the Solomon Islands and by telephone. Using a semi-structured questionnaire, each interview lasted approximately one hour. A research trip to Samoa was cancelled due to the tsunami. Ethics approval was received through the University of Sydney. In the first paper (see Negin 2010a), criteria to assess the implementation of SWAps in different countries and conditions were identified from global experience. The norms that generally should accompany a SWAp include the adoption of an agreed sector plan, ownership of the process by the recipient government, a working partnership among donors and between donors and recipients, increased funding together with longer term donor commitments, pooled funding, sufficient institutional capacity and good governance in recipient countries and stability of donor and recipient country personnel. Based on evidence provided in the second paper (see Negin 2010b), Table 1 summarises the situation in Samoa and the Solomon Islands. Generally, strong political leadership and a sense of ownership characterised the process in Samoa, where the implementation of the SWAp was more effective. In the Solomon Islands, instability in the political situation and the failure of donors to agree on how to move towards a SWAp made the process more difficult. The difficulties of working in a post-conflict state have been recognised (Vergeer, Canavan et al 2009). The main lessons from the SWAp experience in Samoa and the Solomon Islands are outlined in the following sections. A number of points must be noted. First, the analysis does not aim to evaluate the efficacy of these SWAps but rather to examine the lessons from the process of establishing them. Secondly, in general, the implementation of SWAps is complex and difficult and requires careful design and planning. As AusAID (2006a) explains, policy, strategic and administrative frameworks and procedures for implementing a sector-wide program are complex and their development represents a major achievement. Thirdly, it is critical to understand the context of health policy reform and the prevailing conditions in the Pacific and in other low- and middleincome countries; any policy must be adapted to the local situation.
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Table 1. Assessment of Elements of a Sector-Wide Approach in Samoa and the Solomon Islands
SWAp Elements Agreed health sector plan Ownership by partner government Samoa SWAp Available and used as basis for SWAp despite problems with baseline benchmarks Despite initial difficulties in the Ministry of Finance-MOH relationship, consensus that the SWAp is now owned by government Strong collaboration between four main actors: government, NZ, World Bank, Australia Five year commitments of additional resources Yes: pooled funding between all four major actors, but not through government systems. Strong capacity but financial management systems need strengthening Stability within MOH; transition from AusAID to NZAID had difficulties Solomon Islands SWAp Available and used despite some concerns with performance orientation Poor ownership by government throughout SWAp development, with some very recent encouraging signs Very contentious early history among donors has recently turned a corner Limited commitments with some players only recently joining SWAp Only Australia providing budget support though other partners are slowly seeking to streamline funding Generally weak capacity but national financial management systems are being used by SWAp High turnover of consultants and MOH executive

Partnership between all or most donors and partner governments and among donors Increased funding availability and longer term commitments Efforts to streamline funding arrangements

Institutional capacity and good governance

Stability of donor and partner government personnel

Notes: MOH-Ministry of Health; NZ-New Zealand Source: Based on Negin (2010b).

ELEMENTS OF THE SECTOR-WIDE APPROACH

Health Sector Plans and Country Ownership
Recipient country ownership of reform and governance is a strong predictor of success for SWAps. However, most interviewees consulted in this study agreed that AusAID and the World Bank took the initiative in introducing the SWAp mechanism in the Pacific region even while presenting SWAps as what one interviewee called a panacea that puts governments in the drivers seat. AusAID (2009a) has acknowledged shortcomings, admitting that AusAIDs efforts to promote a SWAp in the health sector had stalled in Vanuatu in 2005 and struggled initially in Solomon Islands; in both cases this may have been due to a lack of government ownership (Isom 2006). As AusAID notes, attempts to drive policy reform in the absence of leadership commitment in the Pacific have been less successful and introduction of SWAps has generally depended more on donor activity. Experiences in Samoa and the Solomon Islands are different. In Samoa, the Ministry of Finance drove the initial development of the SWAp process across government, with the Ministry of Health (MOH) driving the process in the health sector. In its Samoa program appraisal, the World Bank (2008a) acknowledged that government ownership was critical to the success of SWAps and that all allocations and activities must be fully consistent with the Health Sector Plan (HSP) priorities. The Samoan SWAp coordination unit is housed and run by the government and the unit reports to the CEO of the MOH rather than to development partners. It is responsible for day-to-day management of the SWAp and comprises a coordinator, program accountant, procurement specialist and four other staff, all of whom are local. Substantial SWAp funds are allocated to strengthening its role in developing and tracking work plans, budgets, progress reports and procurement. The design of the Samoan SWAp puts the onus for management and supervision on the government, noting that the MOH has a supervisory role in relation to all health-related institutions regardless of implementation arrangements at the component level (World Bank 2008a). The institutional structure of the SWAp also supports government ownership. The program steering committee comprises high government officials from the MOH, Ministry of Finance, National Health Service, Ministry of Women, Community and Social Development, Attorney Generals Office and representatives from development partners, other health institutions, the private sector

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and NGOs. A number of intervieweesincluding those who suggested that the SWAp emerged due to donor activityacknowledged that the government was now in the drivers seat. In contrast, recent events in the Solomon Islands highlight the difficulties of achieving government ownership under less stable political conditions (see World Bank 2008b). At a May 2009 health sector review, the various partners agreed to set up a coordination forum that would meet monthly to discuss health sector priorities and issues. The first meeting was held in September 2009. However, the forum was initially established mainly for development partners, and originally the MOH was not invited. In Samoa, the Joint Samoa Program Strategy signed by the government, Australia and New Zealand explicitly endorsed the holding of government-led donor-sector meetings (Governments of Samoa, Australia and New Zealand 2006). All the SWAp-related forums in Samoa are chaired by staff from the MOH or Ministry of Finance. In the Solomon Islands, a MOH representative was eventually invited to attend the first forum meeting, and while this was agreed to, the MOH does not chair the forum and is not expected to drive the agenda. Currently, the Solomon Islands government does not have a SWAp coordination unit, and while the MOH expressed interest in establishing a SWAp secretariat it does not yet exist. Despite these challenges, the government, along with development partners, is actively exploring management and governance systems that would be most appropriate for the health SWAp. The current National Health Strategy expires in 2010, after which a newly developed strategy will begin. As one interviewee noted, the development of the new strategy will be a big test of the joint group, especially achieving a commitment to government ownership of the process and of the final document. Another interviewee noted that policy is usually reactive, done on the fly and not with any evidence base.

Partnership and Harmonisation

The Paris Declaration on Aid Effectiveness and the Accra Agenda for Action (OECD 2008) put the case for harmonisation and partnership. AusAID and NZAID have made a commitment to support these principles (AusAID and NZAID 2001). Hutton and Tanner (2004) argue that being involved in a SWAp further implies a commitment to a direction of change.The OECD (2006) prefers to use the term program-based approaches and describes SWAps simply as a way of working, emphasising consultative coordination. According to Hill (2002), the rhetoric of SWAps reflects a conceptual shift from donors to development partners, recipient to partner governments, from assistance to influence, from project identification to negotiation, from conditionality to mutual responsibility, from coordination of donors to resource management by partner governments. However, the nature, meaning and content of the SWAp remain contested. A key theme emerging from interviews conducted for this study was the shift in focus and meaning that SWAps produced within aid coordination. As one interviewee noted, the term has been used without defining it clearly. Nonetheless, most interviewees noted a welcome shift away from the idea that SWAps are simply about pooled funding and financial management, to a new concept that highlights dialogue, long-term planning, consistency, harmonisation, budgeting and partnerships. Overall, interviewees agreed that a SWAp is more a process than a defined tool. In the Solomon Islands, for example, the focus of the SWAp is more on partnership and coordination than on procurement mechanisms and pooled funding. But while funds might not be pooled, there are efforts to ensure that the donors are being more transparent to the government about how much money and technical assistance they have available and how it should be allocated. One interviewee noted that an emphasis on pooled funding sets up different tiers of development partners, with some more engaged than others, thus exacerbating tension between partners. In Samoa it appears two tiers of SWAp partners have been created: the World Bank, AusAID and NZAID are SWAp partners; the Secretariat of the Pacific Community (SPC), World Health Organisation (WHO) and other United Nations agencies are classified as non-pool partners who simply attend meeting and share information to ensure there is no duplication in programs.

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While pooled funding may no longer be seen as the central component of SWAps, the use of country systems remains a pillar of the Paris Declaration and Accra Agenda. Some assert that the use of country financial management systems can have a very significant impact on systems strengthening. According to the OECD (2009), when donors use country systems they contribute to strengthening them, enhancing the countrys sense of ownership of its development process and reflecting more appropriately the countrys own institutions and traditions.

Funding and Streamlining

SWAps are seen by some commentators as large, complicated, donor-driven structures implemented using a top-down and pre-defined approach. Flexibility of systems and procedures has, however, been noted as an important determinant of a successful SWAp. According to Walt, Pavignani et al (1999), at the point of introduction of a new instrument, when little experience existed on how to move forward, it is helpful to avoid blueprints, to have few rules and to allow considerable flexibility. AusAID too has acknowledged that for sector programs there is no single blueprint (AusAID 2006b). And as one interviewee noted, we should not focus on designing a perfect system but rather aim for one that works in the local context. Walt, Pavignani et al (1999) have cautioned that donors must be prepared to allow rates of disbursement to slip, at least while systems are developed. A too cautious approach by most donors does not mesh well with the aim of strengthening government systems in low- and middle-income countries, especially in post-conflict settings where failure may carry even greater risks (Vergeer, Canavan et al 2009). In Samoa, the World Bank appraisal (World Bank 2008a) explicitly noted the need to build flexibility into the system, so that priorities and procedures could be changed through an annual review process to ensure that systems best reflect current needs. Consequently, specific program expenditures for the entire five-year duration of the program were not defined ex ante, as is usual in investment-project operations. Rather, a framework for setting annual allocations based on sector performance, agreed priorities and available funds was established. Annual health summits in Samoa, one of which was scheduled for March 2010 and another review in September 2010, include representatives from government, NGOs and donor partners both from within the SWAp and others. Such meetings provide a platform for planning future activities and establishing donor financial contributions.

Impact on Transaction Costs

Despite the new emphasis on partnership, pooled funding remains an important issue. The rationale for pooling is that it leads to a reduction in transaction costs by overcoming duplication of donor planning and budgeting activities, commonly supported by different reporting formats. Nonetheless, international evidence suggests that transaction costs may actually increase in the first few years of SWAp implementation (World Bank 2009). A 1999 study in Bangladesh showed that operating the SWAp cost more than US$1 million per year and employed 11 officials (Buse 1999). Interviewees also acknowledged this, some saying that the jury is still out on the transaction costs, others admitting that SWAps probably do increase transaction costs in the early years due to the complex negotiation of new procedures. A recent AusAID (2009b) report agreed that moving to sector approaches takes a great deal of effort on the part of governments and development partners. Interviewees highlighted a few areas where transaction costs (or perceived transaction costs) might rise. First, because more donors are engaged and are providing more money, there are new tasks and greater administrative complexity. One interviewee in Samoa said the SWAp was incredibly ambitious because we implemented 45 initiatives in the first year. Secondly, transaction costs can be seen to increase as performance standards are raised. For example, as more stringent and effective procurement rules are introduced, there can be a perception that costs have increased. In Samoa, interviewees noted that the government did not like World Bank procurement procedures and saw them as a handbrake. Despite this, most stakeholdersthough not the governmentagreed that the regulations themselves were necessary and sound.

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Institutional Capacity and Development Partner Personnel

The project approach to aid delivery involves achieving clearly defined short-term targets. With a SWAp there is more focus on building up government systems over time. AusAID (2009c) acknowledges that the provision of technical assistance needs to be conceived of differently in the context of the Paris Declaration and Accra Agenda. AusAID (2009b) has admitted that, despite formal commitments, it has been difficult both for recipient governments and for development partners to move past entrenched habits. This was confirmed by officials in the Solomon Islands, who noted: We dont have experience in SWAps and nor do our development partners we have much to learn and so do our partners. While more focus has been placed on the difficulties for recipients in adjusting to a SWAp, SWAps also require a change in approach by donors that may reveal gaps in capacity and other shortcomings. One interviewee commented that all parties jumped from stand-alone projects right into SWAps, and the need for greater relationship skills was repeatedly brought up by interviewees. Many interviewees noted that, in selecting foreign advisers, aid agencies commonly hired generalists who did not necessarily have the skills needed to negotiate complex SWAp arrangements or work closely with governments. AusAID has acknowledged shortcomings in the development of SWAps in the Pacific region. According to one report (AusAID 2009a), both the Papua New Guinea (PNG) and the Solomon Islands health SWAps followed a traditional project-style approach; initial support for the design of the PNG SWAp used a team dominated by Australian staff, with only one representative from the National Department of Health and no involvement of other development partners. The project approach often involves considerable expenditures on foreign technical advisers. In the Solomon Islands, for example, 10-15 full-time foreign health advisers are provided collectively by AusAID, the World Bank, WHO and the SPC. One interviewee suggested that it would be more appropriate to put in place a few management aides who knew how to work within government to satisfy the greater need for long-term mentoring than for provision of technical skills. Within a SWAp, the quantity and type of technical assistance needed should ideally be determined by the recipient government, with foreign advisers reporting directly to ministry officials. Technical assistance that substitutes for the work of the ministry, in the words of one interviewee, limits ownership by governments. The Samoan health SWAp had one foreign adviser working on procurement and another appointed for program management. In the Solomon Islands, the assistance provided by the NZAID-European Union education SWAp was heralded by many interviewees as the gold standard in which the adviser provided effective mentoring and built ministerial capacity. A longer-term perspective is needed for implementation of SWAps. The successful Solomon Islands education SWAp, for example, took three to four years to gain traction and only then began to run well, according to observers. A similar situation has been observed in Malawi (Mtonya and Chizimbi 2006; Carlson, Boivin et al 2008).

Pacific Aid Effectiveness Principles

Despite donor commitments to harmonisation and alignment, many regional programs are inadequately linked to national health plans and sectoral efforts. Coordination efforts were criticised by almost all interviewees, from both recipient governments and development partners. In practice, there is inconsistency between donor statements, actions and policies. For example, while AusAID seeks to adhere to the Paris Declaration principles, one interviewee claimed that Canberra still demands that recipients report short-term successes and attribute specific progress to Australian funding. One interviewee said there was intense pressure to get quick runs on the board to appease people back home. Another interviewee accused AusAID of speaking out of both sides of its mouth when it funded project-based vertical programs that require rapid results, like malaria control in Melanesia, despite its acceptance of SWAp principles.
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While in the Solomon Islands the malaria program is supported and managed by a number of partners, including the Global Fund to Fight AIDS, Tuberculosis and Malaria managed through the SPC, the Japanese International Cooperation Agency, Rotarians Against Malaria and the AusAID-funded Pacific Malaria Initiative, according to interviewees these four programs are not well coordinated. Even so, development partners have made some progress towards harmonising malaria efforts with broader sectoral initiatives, with AusAID starting to channel discretionary funds from its malaria program through SWAp mechanisms. Inconsistency also arises from donors who remain outside the SWAps, such as the Global Fund and the new Pacific HIV Response Fund, for which AusAID and NZAID funding is managed through the SPC. Both of these funds maintain parallel mechanisms in the Pacific countries. The main regional technical body in the health sector, the SPC, is not a signatory to the SWAp partnership agreements in either Samoa or the Solomon Islands. Its absence was challenged by participants in the recent health sector review in the Solomon Islands. One interviewee noted that the SPC is being left behind in these harmonisation efforts. Table 2 below summarises the qualitative assessment of adherence to aid effectiveness principles in Samoa and the Solomon Islands. The Samoan health SWAp generally adheres more closely to the Pacific Aid Effectiveness Principles than does the SWAp in the Solomon Islands. Though some shortcomings have been highlighted by the government and partners in the use of national procurement mechanisms and some monitoring and evaluation procedures, the high level of country ownership, aligned planning mechanisms and targeted technical assistance show that the Samoan SWAp is achieving progress against mutually agreed development principles. In the Solomon Islands, however, progress has been seen only more recently, while establishing a sense of government ownership remains the greatest challenge.
Table 2. Adherence to Pacific Aid Effectiveness Principles by the SWAps in Samoa and the Solomon Islands
Pacific Aid Effectiveness Principle Principle 1: Country ownership through national development planning that is adequately resourced using national budget and financial management systems Principle 2: Multi-year commitments by development partners and countries aligned to nationally identified priorities as articulated in national strategies, with agreement on performance indicators and M&E mechanisms Principle 4: Development partners and countries pursue a coordinated and harmonised approach in the delivery of assistance Samoa SWAp Adherence High level of national ownership and uses national financial management system but still uses World Bank procurement mechanisms Multi-year commitments made by multiple donors and government based on national health sector plan. Some have claimed that performance indicators need improvement There is a coordinated approach, but interviewees asserted that processes have overshadowed delivery Solomon Islands SWAp Adherence Low level of country ownership, with recent encouraging signs over past few months

Large number of agencies in partnership agreement based on national plan. Greater harmonisation structures recently launched

Coordination of aid delivery was on the agenda of the health sector review and was acknowledged as priority. Coordination forum held first meeting in September 2009 AusAID is working through local systems, and World Bank is engaged in building capacity of national financial management Some interviewees criticised the quality of technical assistance as being too focused on doing rather than building M&E framework being developed in 2009 according to World Bank project appraisal

Principle 5: Strengthened institutional mechanisms National procurement systems not and capacity in countries to enable increased use currently used by SWAp, but efforts of local systems by development partners being made to build capacity so that switch can be made Principle 6: Provision of technical assistance, including in aid coordination/management, that ensures that capacity is built with tangible benefits to the country to support national ownership Principle 7: Use of an agreed M&E framework that will ensure joint assessments of the implementation of agreed commitments on aid effectiveness Capacity is already strong and strengthening of financial management capabilities is ongoing There is an agreed M&E framework but some have lamented lack of baseline data and need for DHS

Note: M&E-Monitoring and Evaluation; DHS-Demographic and Health Survey

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CONCLUSIONS AND LESSONS FOR HEALTH POLICY IN THE PACIFIC REGION

The experience of implementing SWAp arrangements in Samoa and the Solomon Islands gives rise to a number of lessons that may be of value both to donor agencies and to Pacific Island Countries. The practice and implementation of SWAps varies widely, as the two examples described here testify, and there are no a priori approaches that suit every situation. Underlying the differences in Samoa and the Solomon Islands are different political conditions. Political stability in Samoa allowed the more active participation of the government and a greater sense of ownership; instability in the Solomon Islands led to the initial development of a SWAp without strong government ownership.

Partner Government Ownership

SWAps are used differently in different situations and may be donor-driven or owned by partner governments. There was general agreement in Samoa and the Solomon Islands that the original idea for SWAps emerged from donors. The specific process by which SWAps were agreed was unclear, and policy change was not viewed by interviewees as transparent. According to some interviewees, the general concepts related to coordination emerged in the region over the course of the last two decades; most agreed that the explicit idea of using program approaches in the Pacific emerged more from internal discussions among donors. In the Solomon Islands in particular, some people have questioned the extent to which real government ownership will be possible. To achieve ownership therefore requires a conscious effort and capacity building activities on both sides of the aid relationship.

Partnership and Coordination

Moving from a project- to a program-based mode of aid delivery is neither simple nor clear. In some cases, the implementation of SWAps initially adopted a project approach, as in the Solomon Islands. Moreover, the implementation of donor programs, including SWAps, has not always been aligned with partner government national health plans. The notion of partnership has therefore had a contested meaning, between both donors and governments and between donors themselves. Tensions evident in the relationship between the World Bank and AusAID in the Solomon Islands in 2007 demonstrated the sometimes complex dynamics between donors. Different approaches to procurement regimes and fund holding emerged when the World Bank sought to use its own systems (which it believes to be technically sound and reliable) while the government and AusAID proposed to use mechanisms housed within the MOH. The situation may have been resolved, but donors acknowledged that they were still learning lessons and trying to improve processes. A major issue for SWAps is which organisations join in pooled funding and which remain outside. Clearly, the move from pooling to joint planning, harmonisation and alignment is a major one that must be viewed as an ongoing process requiring constant attention.

Relationships are Critical

There is no blueprint for SWAp implementation. Understanding SWAps as a process underlies the need to maintain flexibility in implementation and constant reassessment within the donor-government relationship. Interviewees asserted that building relationships is particularly important in the Pacific region and the donor way of doing business often does not sufficiently address this adequately. One interviewee noted, that some Pacific Islanders are not going to speak their mind to donors in formal meetings, so while it might seem that there has been agreement, that may not be the case. Others noted the consensus culture that requires more discussion and agreement than Western hierarchical models. A few interviewees emphasised courtesy and protocol as being important elements of dialogue that were at odds with the manner of some development partners. The high turnover of staffof both donor and ministry representativesexacerbates relationship challenges.

Building Implementation Capacity

In the short term, the transaction costs of SWAp implementation may be high, representing in fact a shift of duties from donor to partner government institutions. Longer-term efficiencies in aid delivery may emerge, however, as local administrative procedures replace more expensive donor arrangements. It is clear that

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capacity must be built on both sides of the donor-government relationship in order to make the transition effective. There was common agreement that limited local capacity is a constraint on health policy development in the region. Donor capacity for SWAp implementation has at times been weak; it is evident that the policy preferences of the World Bank and other donors, such as AusAID, have played a more important role than efforts to understand local governance capabilities (Hook 2009). While SWAps also require strong domestic institutions and governance systems, in the Solomon Islands one interviewee asserted that the level of maturity was not yet reached where government could take the reins of the SWAp. But the strength of local institutions is not always the determining factor. While in the Solomon Islands AusAID channels its funding through government systems, in Samoa, where government capacity is stronger, funds are still managed through World Bank procurement processes. A recent AusAID report (2009a) acknowledged the importance of the capacity issue, but concluded that the organisation had conducted insufficient analysis of the nature of the capacity problem and the scope for addressing it.

Aid Effectiveness and Service Delivery

There are inconsistencies in the SWAp processes in Samoa and the Solomon Islands that limit the effectiveness of aid delivery, and some interviewees expressed concern about the ultimate outcomes of the SWAp process. Current health policy involves a strong focus on procedures, inputs and management but less on implementation, performance and activities. According to one interviewee, SWAps have helped us understand the damage donors can do when they distract governments from the core business of service delivery. Despite its intention to pool resources in support of a common sector plan, AusAID (2009b) has noted the extensive accounting and other procedural requirements imposed by development partners can work against the timely use of funds for service delivery. According to the World Bank (2009), there is little evidence that the SWAp by itself has had a positive impact on the effectiveness of the sectoral programs and policies. One interviewee said: We are a long way from having sound discussions about implementation of priorities with governments and with development partners, and the nuts and bolts of service delivery are ignored. As Walt, Pavignani et al (1999) observed, coordination and management of external resources are inherently unstable and remain a challenging process for all involved. This analysis of SWAp developments in Samoa and the Solomon Islands highlights a number of health policy challenges. From an examination of the two SWAps emerge issues related to evidence-based policy making, the importance of relationships, donor-donor and donor-recipient relationships and inconsistencies in aid terminology. Overall, the SWAp processes in Samoa and the Solomon Islands reveal the ongoing complexity and challenges of policy reform and development. At the August 2009 Pacific Islands Forum in Cairns, Australia (Pacific Islands Forum 2009), member countries made a commitment to greater development cooperation and coordination. The issues emerging from this study may provide a guide to Pacific region policy makers involved in SWAp development and help to inform discussions across a range of policy areas.

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REFERENCES
AusAID. 2006a. Solomon Islands annual program performance update FY 2006-07. Canberra: Commonwealth of Australia. AusAID. 2006b. Helping health systems deliver: a policy for Australian development assistance in health. Canberra: Commonwealth of Australia. AusAID. 2009a. Australian aid to health service delivery in Papua New Guinea, Solomon Islands and Vanuatu: Evaluation Report. Canberra: Commonwealth of Australia. AusAID. 2009b. Tracking development and governance in the Pacific. Canberra: Commonwealth of Australia. AusAID. 2009c. Technical assistance personnel: Frequently asked questions. Canberra: Commonwealth of Australia. AusAID and NZAID. 2001. Harmonising donor policies and practices in the Pacific. Canberra: Commonwealth of Australia. Buse, K. 1999. Keeping a tight grip on the reins: Donor control over aid coordination and management in Bangladesh. Health Policy and Planning September, 14 (3): 219-228. Carlson C., M. Boivin, A. Chirwa et al. 2008. Malawi health SWAp mid-term review. Summary report. NORAD Collected Reviews 22/2008. Cassels, A. (1997). A guide to sector-wide approaches for health development: concepts, issues and working arrangements. Geneva, World Health Organisation. Chansa, C., J. Sundewall, D. McIntyre, G. Tomson and B.C. Forsberg. 2008. Exploring SWAps contribution to the efficient allocation and use of resources in the health sector in Zambia. Health Policy and Planning 23: 244251. Gilson, L. and N. Raphaely. 2008. The terrain of health policy analysis in low and middle income countries: A review of published literature 1994-2007. Health Policy and Planning 23 (5): 294-307. Governments of Samoa, Australia and New Zealand (2006). Joint Samoa program strategy 2006-2010. Hill, P.S. 2002. The rhetoric of sector-wide approaches for health development. Social Science and Medicine 54 (11): 1725-1737. Hook, S.M. (2009). Institutional reform and state capacity in the South Pacific. Pacific Economic Bulletin 24 (2): 155-167. Hutton, G. and M. Tanner. 2004. The sector-wide approach: a blessing for public health? Bulletin of the World Health Organisation 82 (12): 893. Isom, T. 2006. The experience of health reform in Vanuatu. PNG Medical Journal 49 (3-4): 108-11. Mtonya, B. and S. Chizimbi. 2006. System-wide effects of the Global Fund in Malawi: Baseline study report. Bethesda, MD: Abt Associates. Negin, J. 2010a. Sector-Wide Approaches for health: an introduction to SWAps and their implementation in the Pacific region. Health Policy and Financing Knowledge Hub Working Paper No. 2 Melbourne: Nossal Institute for Global Health. Negin, J. 2010b. Sector-Wide Approaches for health: a comparative study of experiences in Samoa and the Solomon Islands. Health Policy and Financing Knowledge Hub Working Paper No. 3 Melbourne: Nossal Institute for Global Health. OECD. 2006. Harmonising donor practices for effective aid delivery, Volume 2. Paris: OECD. OECD. 2008. The Paris Declaration on Aid Effectiveness and Accra Agenda for Action. http://www.oecd.org/dataoecd/30/63/43911948.pdf (accessed March 2010)

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OECD. 2009. Managing development resources: The use of country systems in public financial management. Paris: OECD. Pacific Islands Forum Secretariat. 2009. Cairns compact on strengthening development coordination in the Pacific. Forum Economic Ministers Meeting, Rarotonga, Cook Islands 27-28 October 2009. Session 2 Paper. http://www.forumsec.org.fj/resources/uploads/attachments/documents/FEMM%2009%20Paper%20on%20 Cairns%20Compact.pdf (accessed March 2010) Vergeer, P., A. Canavan and I. Rothmann. 2009. A rethink on the use of aid mechanisms in health sector early recovery. Amsterdam: Development Policy & Practice. Walt, G. and L. Gilson. 1994. Reforming the health sector in developing countries: The central role of policy analysis. Health Policy and Planning 9 (4): 353-370. Walt, G., E. Pavignani, L. Gilson and K. Buse. 1999. Managing external resources in the health sector: are there lessons for SWAps? Health Policy and Planning 14(3): 273284. World Bank. 2008a. Project appraisal document of the World Bank on a proposed credit in the amount of SDR 1.9M to the independent state of Samoa in Support of Health Sector Management Project. World Bank. 2008b. Project appraisal document of the World Bank on a proposed grant in the amount of SDR 1.0M to Solomon Islands for a health sector support program technical assistance project. World Bank. 2009. Improving effectiveness and outcomes for the poor in health, nutrition, and population: An evaluation of World Bank group support since 1997. Washington, DC: World Bank.

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