How is the public Interest protected? alistic expansion of the publicly funded health care system, sometimes well in excess of national economic growth. Eventually, the policy and planning document is seen as infeasible and is ignored. Box 6. 1 sketches how comprehensive health planning has given way to a more flexible framework' approach Ghana,s 1995 medium-term health strategy identified ten ways in which the health system would contribute towards better health(see Box 6.2) Public consultation occurs in some countries at the beginning of the policy formulation rocess.a"rolling framework is sometimes used, and periodically updated and amended In countries where extemal assistance forms an important part of the health systems re sources, an important expansion of this approach to policy-making and implementation is represented by sector-wide approaches(SWAPs). The essence of SWAPs is that, under government leadership, a partnership of funding agencies agrees to work together in sup port of a clear set of policy directions, often sharing many of the implementation proce- dures, such as supervision, monitoring, reporting, accounting and purchasing. Box 6.3 summarizes the development of SWAPs. Health planning thus shows signs of moving beyond investment programming and towards consensus statements on broad lines of policy and system development. A policy framework should recognize all three health system goals and identify strate- gies to improve the attainment of each. Few countries have explicit policies on the overall goodness and faimess of the health system. Yet the need to combine these two values in governance can be traced far back in history(1). Box 6.4 describes the ancient Hisba system of stewardship in Islamic countries, highlighting both its ethical and economic purpo Public statements about the desired balance among health outcomes, system responsive ness and faimess in financing are yet to be made anywhere. Policy should (and in partial Box 6.3 SWAPs: are they good for stewardship Asector-wide approach (SWAP)is the comprehensive attainment of all Zambia. The other duster of coun- operate within a single sector a method of working that brings these different elements from the tries discussing or actively engaging policy and medium-term ex together governments, donors, start. t implies changes to the ways in a SWAP is in Asia: Bangladesh, penditure framework. Joint re- and other stakeholders within any in which both governments and Cambodia, and Viet Nam are exam- view missions have become a sector. It is characterized by a set donor agencies operate, and in their ples. feature in some countries Least of operating principles rather than required staff skills and systems. The evolution of a SWAP takes progress has been made towards specific package of policies or This approach has begun to take time. In Ghana, before the Ministry common financing and procure- activities. The approach involves root primarily in some of the most of Health single sector programme ment arrangements ernment leadership towards: has been driven by both govern- try had already gone through 10 support good stewardship. Walt broadening policy dialogue; devel- ment and donor concerns about the years of institutional development, and colleagues argue that SWAPs oping a single sector policy (that results of historical approaches to 4 years of major policy /strategy are perceived as capable of addresses private and public sec- development assistance, which have work, 3 years of strengthening core strengthening governments'abil- tor issues)and a common, realis- often involved a combination of so- management functions, 2 years of ity to oversee the entire health expenditure programme: cial sector- blind macroeconomic negotiations, planning and design, system, develop policies and en- common monitoring arrange- adjustment policies and sector- and 1 year of slippage and delays. gage with stakeholders beyond ments;and more coordinated fragmenting projects. Many of the Cambodia and Viet Nam are at the the public sector But, most im- procedures for funding and pro- countries are in Africa, for example, earliest stage of discussing sector portantly, SWAPs depend on vi- curement Being engaged in a Burkina Faso, Ethiopia, Ghana, Mali, policy with donors. In other coun- sion and leadership by national SWAP implies commitment to this Mozambique, Senegal, Uganda, the tries, progress has been mostly to- government. direction of change, rather than United Republic of Tanzania, and wards developing and agreeing to n P. Cited in Foster M Lessons of experience from sector-wide approaches in health. Geneva, World Health Organization, Strategies for Cooperation and Partnership, 1999 Walt Get al. Managing extemal resources in the health sector are there lessons for SWAPs? Health Policy and Planning, 1999, 14(3): 273-284.How is the Public Interest Protected? 123 alistic expansion of the publicly funded health care system, sometimes well in excess of national economic growth. Eventually, the policy and planning document is seen as infeasible and is ignored. Box 6.1 sketches how comprehensive health planning has given way to a more flexible ‘framework’ approach. Ghana’s 1995 medium-term health strategy identified ten ways in which the health system would contribute towards better health (see Box 6.2). Public consultation occurs in some countries at the beginning of the policy formulation process. A “rolling” framework is sometimes used, and periodically updated and amended. In countries where external assistance forms an important part of the health system’s re￾sources, an important expansion of this approach to policy-making and implementation is represented by sector-wide approaches (SWAPs). The essence of SWAPs is that, under government leadership, a partnership of funding agencies agrees to work together in sup￾port of a clear set of policy directions, often sharing many of the implementation proce￾dures, such as supervision, monitoring, reporting, accounting, and purchasing. Box 6.3 summarizes the development of SWAPs. Health planning thus shows signs of moving beyond investment programming and towards consensus statements on broad lines of policy and system development. A policy framework should recognize all three health system goals and identify strate￾gies to improve the attainment of each. Few countries have explicit policies on the overall goodness and fairness of the health system. Yet the need to combine these two values in governance can be traced far back in history (1). Box 6.4 describes the ancient Hisba system of stewardship in Islamic countries, highlighting both its ethical and economic purposes. Public statements about the desired balance among health outcomes, system responsive￾ness and fairness in financing are yet to be made anywhere. Policy should (and in partial Box 6.3 SWAPs: are they good for stewardship? A sector-wide approach (SWAP) is a method of working that brings together governments, donors, and other stakeholders within any sector. It is characterized by a set of operating principles rather than a specific package of policies or activities. The approach involves movement over time under gov￾ernment leadership towards: broadening policy dialogue; devel￾oping a single sector policy (that addresses private and public sec￾tor issues) and a common, realis￾tic expenditure programme; common monitoring arrange￾ments; and more coordinated procedures for funding and pro￾curement. Being engaged in a SWAP implies commitment to this direction of change, rather than the comprehensive attainment of all these different elements from the start. It implies changes to the ways in which both governments and donor agencies operate, and in their required staff skills and systems. This approach has begun to take root primarily in some of the most highly aid-dependent countries. It has been driven by both govern￾ment and donor concerns about the results of historical approaches to development assistance, which have often involved a combination of ‘so￾cial sector-blind’ macroeconomic adjustment policies and ‘sector￾fragmenting’ projects. Many of the countries are in Africa, for example, Burkina Faso, Ethiopia, Ghana, Mali, Mozambique, Senegal, Uganda, the United Republic of Tanzania, and Zambia. The other cluster of coun￾tries discussing or actively engaging in a SWAP is in Asia: Bangladesh, Cambodia, and Viet Nam are exam￾ples. The evolution of a SWAP takes time. In Ghana, before the Ministry of Health single sector programme was endorsed by donors, the coun￾try had already gone through 10 years of institutional development, 4 years of major policy/strategy work, 3 years of strengthening core management functions, 2 years of negotiations, planning and design, and 1 year of slippage and delays.1 Cambodia and Viet Nam are at the earliest stage of discussing sector policy with donors. In other coun￾tries, progress has been mostly to￾wards developing and agreeing to operate within a single sector policy and medium-term ex￾penditure framework. Joint re￾view missions have become a feature in some countries. Least progress has been made towards common financing and procure￾ment arrangements. SWAPs have the potential to support good stewardship. Walt and colleagues argue that SWAPs are perceived as capable of strengthening governments’ abil￾ity to oversee the entire health system, develop policies and en￾gage with stakeholders beyond the public sector.2 But, most im￾portantly, SWAPs depend on vi￾sion and leadership by national government. 1 Smithson P. Cited in Foster M. Lessons of experience from sector-wide approaches in health. Geneva, World Health Organization, Strategies for Cooperation and Partnership, 1999 (unpublished paper). 2 Walt G et al. Managing external resources in the health sector: are there lessons for SWAPs? Health Policy and Planning, 1999, 14(3): 273–284