Rethinking Health Sector Wide Approaches through the lens of Aid Effectiveness

Sector Wide Approaches (SWAps) are an approach to aid management that aim to support recipient government leadership. Health aid has grown rapidly in the past 20 years and in this time SWAps have become an important health aid delivery approach. However, the empirical evidence is that the performance of health SWAps is, at best, mixed. Outcome and impact benefits of health SWAps are inconclusive, and overall process level performance is poor. The key insight offered by this paper is that a divergence has developed between the underlying theory of change of health SWAps, and their implementation. The paper argues the theory of change underlying SWAps is highly consistent with effective aid, however the practice is not. Health SWAps have been characterised by cumbersome architecture that is partially implemented and used, and which does not facilitate government ownership and commitment to indigenous institutional development. A core stream of the analysis as to why this is the case relates to technical shortcomings within the SWAp architecture itself, however this is not sufficient to understand the reasons for the limited success of SWAps. Rather it is clear there are a range of broader incentives and understandings within both donors and governments that have shaped the implementation of SWAps at a process level. The paper concludes with some suggested actions which may assist in realigning health aid with the underlying SWAp theory of change, whilst taking into account at least some of the incentives and understandings that have cut across SWAp implementation. The essence of the proposed approach is a more realistic understanding of the nature of health systems, combined with a more politically informed set of strategies to support the development of these systems.