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New Report Finds Significant Investments in Broad Sector-Wide Approaches Are Not Producing Intended

http://www.action.org

Washington DC - A new report released today shows that the World Bank and other development agencies have invested billions of dollars over the last decade in an approach to health that is not achieving intended outcomes. The new report "Aid Without Impact" found little evidence that sector-wide approaches (SWAps) have been associated with improved health outcomes in low-income countries in sub-Saharan Africa. Specifically, the report examined the use of SWAps for improving health, with particular attention to their impact on TB. The report was released by ACTION (Advocacy to Control TB Internationally), a project funded by the Bill & Melinda Gates Foundation.

"Given the global economic crisis, now more than ever we must ensure that aid is good value for money and delivers planned results," said Richard Skolnik, former manager of the World Bank's health, nutrition, and population programs in South Asia and one of the authors of the report. "Unfortunately, this report shows that important support from the World Bank and its partner agencies for health in Africa is not improving the health of the poorest Africans as planned."

The release of this report coincides with an upcoming replenishment meeting where the World Bank will plan for how to best secure billions of dollars in new funding from donors. "The World Bank is fundraising this year from the perspective that its aid is needed now more than ever," said Paul Jensen, policy analyst for ACTION and an author of the report. "As donor governments provide financing for the Bank, they must demand that support for Africa deliver better health for the poorest people. Our report shows that donors may get a bigger bang for their buck elsewhere, unless substantial changes are made to the SWAps approach.  In fact, the findings of our report are similar to those of a recent evaluation from the World Bank's own Internal Evaluation Group. The issue now is whether or not the development community will act on these findings and improve the effectiveness of its assistance."

Sector-wide approaches, or SWAps, emerged in the late 1990s in response to certain limitations that were observed in project-based approaches to health. Project-based approaches were narrow in scope and strengthened a distinct part of a country's health program or an area of institutional capacity such as financing the construction of hospitals or the procurement of drugs. However, these were criticized for denying recipient governments ownership, lacking sustainability and fragmenting sector development. In the SWAp model, donors provide support to a recipient government for broad-based improvements in the country's healthcare system. It intends to coordinate donor financing, allow recipient governments to plan investments, and holistically develop the health sector. 

As the world's second leading infectious killer after HIV/AIDS, tuberculosis (TB) remains an exceptional public health threat. With the severity of HIV/AIDS in Africa and TB's increasing resilience to the standard drugs, TB has resurfaced as an urgent global problem requiring effective control. In 2008 there were 9.4 million new TB cases and 1.8 million deaths, 44% of them in Africa. The majority of those with TB in sub-Saharan Africa go undiagnosed, with over 88% of multidrug resistant TB cases unidentified in 2008. While World Bank control efforts in Asia have been implemented through large-scale TB-specific investments, the Bank has pursued a different strategy in Africa - SWAps. 

While the report acknowledged the importance of a SWAp approach to development assistance for health in low-income countries in sub-Saharan Africa, it emphasized that in most countries, SWAps are not being implemented effectively, efficiently, sustainably, or in measurable terms.  Similarly, the World Bank's own Independent Evaluation Group found that "only 4 of the 11 completed projects supported by SWAps had satisfactory outcomes in achieving their relevant program objectives."

The ACTION report identified specific flaws in the approach the World Bank and its partners are taking, including a general lack of attention to results, failure to monitor and ensure country expenditures focus on high priority investments, and weak monitoring and evaluation of health programs that SWAps are supporting. Additionally, the report suggested that the World Bank and its development partners did not pay sufficient attention to improving the control of TB from 2001 to 2008 in their health sector development projects.  These programs in countries with many cases of TB rarely included targets for both finding and curing more people of TB (only 20%). In addition, only a limited impact on curing TB could be associated with SWAps.

The report notes that in order for the World Bank and its partners to develop effective assistance programs for health with better outcomes, they need to recognize the failure of SWAps to meet their aims. They also need to ensure that these programs are independently evaluated, that the results of the evaluations are made public, and that they link their funding to the achievement of results.  They also need to ensure that such programs focus on the health problems that take the greatest number of lives, set reasonable targets for gains in those areas, and more carefully monitor and evaluate their efforts.

Aid Without Impact was developed by ACTION (Advocacy to Control Tuberculosis Internationally), which is an international partnership of advocates supported by the Bill & Melinda Gates Foundation that works to mobilize resources to treat and prevent the spread of TB worldwide.