-I m CD rn CD 0~~~~~~~ =7- n~~~~~~~U 17D ~~~m CA Other Titles in This Series A Chance to Learn: Knowledge and Finance for Education in Sub-Saharan Africa Adult Literacy Programs in Uganda Education and Health in Sub-Saharan Africa A Review of Sector-Wide Approaches World Bank Group Human Development Africa Region Copyright İD 2001 The International Bank for Reconstruction and Development / THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, USA All rights reserved Manufactured in the United States of America First printing January 2001 1 23403020100 The findings, interpretations, and conclusions expressed in this book are entirely those of the authors and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. The World Bank does not guarantee the accu- racy of the data included in this publication and accepts no responsibility for any consequence of their use. 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For permission to reprint individual articles or chapters, please fax a request with complete information to the Republication Department, Copyright Clearance Center, fax 978-750-4470. All other queries on rights and licenses should be addressed to the Office of the Publisher, World Bank, at the address above or faxed to 202-522-2422. Cover photos: UNICEF/HQOO-0002/Pirozzi (upper left photo); The World Bank (lower right photo). ISBN 0-8213-4857-4 Library of Congress Cataloging-in-Publication Data has been appliedfor. Contents Foreword . ................................................................... v Summary of Main Points . .............................................................. vii 1. INTRODUCTION ................................................................... 1 Situation ................................................................... Project Assistance ................................................................ 1 Program Assistance .............................................................. 2 The Development of Sector-Wide Approaches ....................................... 3 The Roots of Sector Investment Programs (SIPs) ................................ 3 SIP Characteristics .......................................................... 4 Innovations in SIPs .............................................................. 5 Purpose of the Review ............................................................ 5 Findings ..................................................................... 6 2. MEETING THE PRECONDITIONS TO START THE PROCESS ............................ 7 3. ESTABLISHING A COLLABORATIVE PROCESS ........................................ 9 Developing Donor-Government Partnerships ........................................ 9 Using National Leadership to Build Ownership and Support .......................... 10 Forging Donor Coordination: Working Together under Government Leadership .... ..... 10 Common Program ......................................................... 10 Common Procedures (or "Harmonization") ................................... 11 Instruments for Coordination ............................................... 12 4. DEVELOPING A POLICY FRAMEWORK .............................................. 15 Requirement 1: Definition of Appropriate Program Scope ............................ 15 Requirement 2: Strong Analytical Underpinnings .................................... 17 Requirement 3: Consultation with Stakeholders ..................................... 18 Requirement 4: A Flexible, Ongoing Process of Policy Development .................... 19 iii CONTENTS 5. DESIGNING APPROPRIATE FINANCIAL PARAMETERS ........ ....................... 21 Setting the Sector within the Macroeconomic Framework ............................. 21 Building a Medium-Term Expenditure Program for the Sector ......................... 22 6. DESIGNING IMPLEMENTATION SYSTEMS ............. ............................. 25 Analyzing Institutional Capacity . ................................................. 25 Monitoring Performance ........................................................ 26 Information Systems ....................................................... 27 Joint Reviews ......................................................... 27 Providing Adequate Resources for Monitoring Implementation ...... ............. 29 Financial Management ........................................................ 30 Budgeting and Expenditures .................................................. 30 Pooling of Donor Funds . ................................................... 31 Lender of Last Resort ....................................................... 32 Procurement ................................................................... 34 7. MAIN FINDINGS AND RECOMMENDATIONS ............ ............................ 37 Successes of the Sector-Wide Approach ............... ............................. 38 Weaknesses ................................................................... 38 Design of Sector Programs . ................................................. 38 Implementation of Sector Programs ............. ............................. 38 Recommendations for Best Practice . ............................................... 39 A. Meet the Preconditions for Starting ............ ............................ 39 B. Establish A Collaborative Process ............. ............................. 39 C. Establish a Comprehensive Policy Framework ............................... 40 D. Develop Financial Parameters . ............................................. 40 E. Build Management Systems and Capacity ................................... 41 Bibliography ................................. .................................... 43 Annex 1: List of World Bank Staff Interviewed ............. ............................. 47 Annex 2: Ethiopia Health Case Study . ................................................. 49 Annex 3: Ghana Health Case Study .................................................... 57 Annex 4: Senegal Health Case Study . ................................................. 75 Annex 5: Zambia Health Case Study . ................................................. 83 Annex 6: Ethiopia Education Case Study . ............................................... 95 Annex 7: The Gambia Education Case Study ............. ............................. 107 Annex 8: Mozambique Education Case Study ............. ............................. 117 Annex 9: Zambia Education Case Study .................. ............................ 131 iv Foreword Dissatisfaction with traditional project approaches Bank with this approach. The commitment to Edu- and a recognition of the limitations of the sector cation for All reaffirmed by all partners at the World adjustment programs led to the development of new Education Forum in Dakar, April 2000, and the ur- lending instruments to improve the impact of de- gency of an acceleration of education development velopment assistance on the sector as a whole. The in Sub-Saharan Africa make the search for more ef- social sectors have been at the vanguard of these in- fective ways of working together for education de- novations in several countries. Within the Africa Re- velopment an inescapable imperative. gion of the World Bank, the most commonly used This is especially important as the Bank2 and such new instrument to provide support for a more several bilateral agencies have explicitly indicated comprehensive sector development program has their intention to use this approach to channel their become known as "Sector Investment Program" support for education development. While the SWAP (SIP).' Other agencies have used different names for is not without problems and is not suitable in all this approach. For example, under the leadership of countries, some adaptation of the SWAP is likely to the European Union, a group of European bilaterals become the most important instrument used by worked along similar lines and developed a strategy external agencies to support accelerated education known as "Sector Wide Approach" (SWAP). development in the Africa region. This paper sum- In recent years this approach-characterized by marizes the lessons we in the Africa Region have a government-led partnership with key external part- learned so far, identifies the strengths and weaknesses ners, based on a comprehensive sector policy and of this approach, and provides advice and guidance expenditure framework, and relying on government to operation staff in the Bank, partner agencies, and institutions and common procedures for implemen- governments who will be involved in sector-wide tation-has been used by the World Bank for about approaches in the years to come. a dozen operations in the health and education sec- This paper was prepared by Richard Johanson tors in Sub-Saharan Africa. under the supervision of Adriaan Verspoor, Educa- This paper is a most welcome review of the ex- tion Lead Specialist in the Africa Region of the World perience to date of the Africa Region of the World Bank, with the assistance of Angel Mattimore.3 Con- 'Peter Harrold wrote the definitive explanation of sector investment programs in his work "The Broad Sector Approach to Investment Lending," World Bank (1995). 2 See The World Bank (2000) "A Chance to Learn: Knowledge and Finance for Education in Sub-Saharan Africa," forth- coming. 3 The findings, interpretations and conclusions expressed in this paper are entirely those of the author and should not be attributed in any manner to the World Bank, its affiliated organizations or to the members of the Board of Executive Directors or the countries they represent. The World Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility for any consequence in their use. v tributions to the paper and case studies were given World Bank). We would like to thank the Norwe- by Arvil Van Adams, Anwar Bach-Baouab, Rosemary gian Government for providing financial support for Bellew, David Berk, Nicholas Burnett, Francois the preparation of this study through the Norwe- Decaillet, Linda Dove, Birger Fredriksen, Donald gian Education Trust Fund. For more information Hamilton, Bruce Jones, Julie McLaughlin, Paud about this book, send an e-mail message to Murphy, Eliezer Orbach, O.K. Pannenborg, Robert afrhdseries@worldbank.org. Prouty, Jee Peng Tan, and Steve Weissman (all of the Birger Fredriksen Sector Director, Human Development Africa Region, The World Bank vi Summary of Main Points Project assistance in Africa has been criticized as frag- Management systems and capacity building mented, donor-driven and lacking impact on basic -' Common implementation structures development problems. In view of the wide-spread and procedures (harmonization of do- limitations of projects, in the early 1990s a new lend- nor procedure-including reporting, ing approach was developed in Africa-the "Sectoral joint annual reviews of performance, Investment Program" The main rationale for this procurement, disbursements to the ex- kind of sector-wide approach was to address weak- tent possible) nesses of the project approach and achieve greater > Use and strengthening of government in- impact with development assistance. The main char- stitutions, procedures and staff (rather acteristics of SIPs are as follows: than external technical assistance) Partnership Sector-wide programs emphasize a process by v Local stakeholders in charge-program which overall policies are translated into strategies directed by government and programs, then into expenditure plans that make o All key donors sign on to the program sense in a long-term national context. This is fol- + Government coordinates donors lowed by annual reviews of actual performance + Broad consultation with stakeholders against the plans and adjustments as appropriate. The emphasis is on process rather than products. Comprehensive sectorpolicyframework Sector-wide programs can be served by different > Sector-wide scope, covering all relevant lending instruments, including specific investment areas, policies, programs, and projects. loans (SILs), sector investment and maintenance > Based on an (a) overall policy for the sec- loans (SIMs), adjustable program loans (APLs), and tor (principles and objectives); (b) strat- Technical Assistance Loans (TALs). egy of measures to achieve policy objectives over the medium term (about Innovations in sector-wide approaches 5 years); and translated into (c) a pro- include: gram of specific interventions in the near + Policy development as a dynamic process, term (2-3 years). not a one-off exercise, to be updated and re- newed as circumstances become clearer or Expenditureframework change. + Overall expenditure program, including + Linkages with the macroeconomic frame- definition of feasible intersectoral allo- work. Resource allocation is derived from cations an overall expenditure framework. o Intrasectoral spending plan, derived from v Clear linkages established among analysis, program priorities policy development, strategic plans, pro- vii SUMMARY OF MAIN POINTS grams, budgets, and implementation evaluation, and (c) set up appropriate finan- through annual reviews. cial mechanisms. (Chapter 5) > The emphasis on harmonization of donor procedures. It is still too early to tell whether sector-wide + The emphasis on use of government struc- approaches in the social sector are making an im- tures and procedures for such functions as pact, but some useful findings can be identified. procurement, financial management, and Sector programs are complex. They involve accounting. broad scope, new procedures, donor coordination, and channeling of external assistance through gov- ernment budgets and the implementation of major FINDINGS FROM THE REVIEW ABOUT reforms. Each of these adds a layer of complexity. SECTOR-WIDE APPROACHES Complexity comes at a price-in terms of time and resources required for sector approaches. Different In the second half of 1999 a review was conducted kinds of staff are required, particularly those adept in the Bank's Africa Region of sector-wide approaches in policy analysis and negotiation. in the social sector. The intended audience of the review was Bank operational staff in the education sector of the Africa region. The review sought to STRENGTHS answer the question: how should a sector program be done? Based on staff interviews, a literature re- Sector approaches have achieved several successes. view, and development of eight case studies the find- Comprehensive plans and strategies were developed ings suggest that a sector program should: in all cases reviewed and in some countries capaci- ties were built for decentralized planning. Stronger c Be developed only in countries that meet links were forged between policies, the allocation of the preconditions. (Chapter 1) funds and performance. Stakeholder consultations . Establish an effective collaborative process- were strengthened and frameworks were established which requires a) developing donor-govern- for donor coordination. Some common procedures ment partnerships, b) following the national were adopted by donors, particularly for joint mis- leadership, and c) forging donor coordina- sions, monitoring, and progress reporting. These tion. (Chapter 2) steps helped reduce the administrative burden on v Establish a proper policy framework - which governments of external assistance. Some programs requires (a) adopting an appropriate scope, have begun to move to budget support by pooling (b) basing it on strong analytical work, (c) external resources and channeling them through the consulting with stakeholders about priori- government budget. Resources allocated for the sec- ties, and (d) continuing the policy develop- tors have also increased under sector programs in ment process during implementation. both absolute and relative terms. (Chapter 3) • Prepare an overall expenditure framework that (a) defines appropriate intersectoral al- WEAKNESSES locations, a feasible resource envelope, and (b) ensures appropriate allocations within Weaknesses identified at the design stage include the the sector; (Chapter 4) and lack of rigorous sector analysis in some cases; the • Establish management arrangements that lack of systematic analysis of implementation capac- (a) analyze and build institutional capacity, ity in most cases (such institutional analysis can be (b) concentrate on effective monitoring and an antidote to overly ambitious programs), and in- viii EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA adequate design of monitoring indicators. During parties can raise and address problems implementation, problems and changes are the rule and their concerns. rather than the exception. This underscores the need 4 Follow government's lead, but ensure for doing better risk analysis and contingency plan- that ownership and participation is in- ning. Other specific problems have been weak data creased progressively from a narrow collection, and disappointment with the outcomes group of reformers and includes par- of joint semiannual reviews. ticipation of central ministries and leg- islatures. c Spell out the rights and responsibilities RECOMMENDATIONS FOR BEST PRACTICE of all parties on paper at the start in a Statement of Intent, and later in a The review concludes with recommendations for best Memorandum of Understanding (or practice and a list of prerequisites for commitment Credit Agreement) and Code of Practice. of funding to sector programs. They are reproduced 4 Harmonize procedures that are feasible below from the main text: immediately, such as reporting, joint reviews, and monitoring systems. Also A. Meet the Preconditions for Starting start with immediate steps to strengthen . Ensure that the prerequisites are met for and improve government systems. Get entering into the development of a sec- central agencies to work on generic sys- tor-wide approach. Do not undertake tems for all sectors, such as finance and a sector-wide approach unless the cli- procurement, rather than repeating the ent has (a) a modicum of stability, (b) work sector by sector. strong commitment to an integrated, c Define the role of a donor lead agency collaborative process, and (c) at least a in advance to avoid misunderstandings. minimum level of institutional capac- Provide sufficient administrative funds ity. In addition, ensure that the donor to pay for the high costs of coordina- agency allocates adequate resources and tion. the right profile of staff for developing > Establish a joint technical assistance a sector program. fund for project preparation to start pooling of resources on a small scale. B. Establish a Collaborative Process .> Do not rush the process of policy de- C. Establish a Comprehensive Policy Frame- velopment. Sector approaches are a long work haul, not a quick fix. Time must be al- v. Distinguish between sector-wide scope lowed for reaching agreements on policy for analytical and for investment pur- issues and interventions, appropriate poses. That is, start with a comprehen- procedures, legislation and clear delin- sive policy framework covering the eation of responsibilities to ensure sector as a whole even if subsequent sustainability (Jespersen: 12) investment programs have to be lim- • Recognize that success ultimately de- ited to particular subsectors. pends on the level of trust among part- * Help build stronger analytical under- ners. Trust, in turn, is based on pinnings for sector-wide programs by openness, transparency, negotiation, improving the quality and rigor of sec- and compromise. Appropriate mecha- tor analysis during initial program nisms must be in place by which all design. .x SUMMARY OF MAIN POINTS Recognize that policy analysis is an im- to avoid the typical delays in disburse- portant ongoing function during pro- ments. gram execution and focus attention on > Where other donor funding is uncer- (i) building local capacity for continu- tain establish a core program of donor ing policy analysis during implemen- assistance with Bank financing, and add tation, and on (ii) building better to the core as additional financing ma- information systems for data collection. terializes. Continue the good work shown on o> Use computer models for expenditure stakeholder consultation. Widen the projections during preparation and use consultations beyond the bureaucracy the same models during implementa- to include front-line service workers and tion for monitoring performance. beneficiaries. Use a clearly defined re- + Spell out the role of the lender of last source envelope to ensure realism and resort. In particular, agree in advance facilitate hard choices among compet- on what specifically is excluded from the ing priorities. expenditure plan. Have explicit policy agreement on ba- + Accept "patchwork" arrangements- sic principles and priorities before loan where donors earmark funds for particu- approval, an explicit list of policies on lar components-only as a step toward which consensus has not yet been the optimal strategy, which is the pool- reached, and a process for reaching ing and channeling of donor funds consensus through further study and through normal government budgets. dialogue. Use an adaptable program loan (APL) with "triggers" set for E. Build Management Systems and Capacity achieving consensus on difficult areas * Use existing techniques for institutional of policy. analysis more systematically and rigor- ouslyto identify and address weaknesses D. Develop Financial Parameters and constraints before embarking on a If it is not possible to invest in the sec- sector program. Go beyond organiza- tor as a whole, nonetheless monitor ex- tional analysis to consider staff incen- penditures sector-wide to ensure tives, identifywho stands to gain and lose reasonable intrasectoral allocations. from program implementation, and plan Conduct public expenditure reviews be- in detail the flow of funds to beneficia- fore commitment of funds to establish ries. Since institutional analysis is costly, an overall resource envelope for the sec- budget the requirements separately and tor. Do not defer this to the implemen- fully in project preparation. Consider us- tation phase. ing an APL to overcome structural con- Use budget ceilings to force better se- straints for later phases. lection of priorities, as when regions Rc Focus early and sharply on the devel- prepare sectoral programs. opment of monitoring and evaluation + Devote attention to the establishment systems. Limit the number of indica- of sound government criteria and pro- tors to priorities and ensure that they cedures for appraisal and selection of tell clearly whether the program is on specific investment projects. track annually. + Meticulously plan the flow of funds + Design joint review procedures in ad- from the center to regions and districts vance and ensure that workable mecha- x EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA nisms are in place to identify, address, demanding than a traditional project. In summary, and resolve problems. Build govern- the following steps should be considered as essen- ment capacity to manage joint reviews. tial prerequisites for commitment of funding (i.e., in Involve financial and procurement spe- place by time of Board presentation) for sector-wide cialists early in the design phase to help operations: in developing appropriate systems. > Link disbursements to achievements to (1) Policy framework developed, based on rig- provide incentives for good perfor- orous sector analysis, including specific mance. three-year work program (Ethiopia educa- > Engage in better risk analysis and con- tion). tingency planning for various types of (2) Wideconsultationswithstakeholdersand do- occurrences. Think through systemati- nors have been held, and agreement reached cally what would happen if critical on priorities. changes happened in (a) the macro-en- (3) Public expenditure review or social sector ex- vironment, e.g., if macroeconomic penditure review completed; overallfinan- shocks reduce sectoral allocations be- cial parameters defined in terms of targeted low planned targets; (b) disagreements intersectoral allocations and a budget enve- arose on the policy framework; and (c) lope for the sector, and agreement on bud- key staff changed. Devise a set of courses get priorities for the first two years (Ethiopia of action for each contingency. For ex- health). ample, assuming that key personnel (4) Institutional capacity analysis completed and inevitably will change, (i) broaden the agreement reached on early implementation participation of stakeholders, (ii) pro- of a program to fill identified gaps (The vide continuous training and briefings Gambia education). for new personnel involved, (iii) involve (5) Monitoring indicators identified that show higher levels in the approval process, clearly whether program implementation is e.g., cabinets, and (iv) root the programs on track; data collection system designed and in legislation. Devise and install rem- in place on processes, system delivery and edies at the design stage in case things impact (Ghana health). do not work out and the program de- (6) The modus operandi designed for joint re- viates markedly from the plan. views and problem resolution, i.e., mecha- After tapping other sources for financ- nisms for common reporting, joint annual ing studies and reviews, be prepared to reviews of progress, budget planning, dis- finance substantially larger-than-nor- cussion of differences. mal budget coefficients for supervision (7) The role of donor of last resort clearly spelled of sector programs, recognizing that out (and specifically what is excluded from ongoing analytical work is costly to re- the agreed expenditure program), and a view and the scope of sector-wide pro- staged plan to achieve pooling of resources grams encompasses the equivalent of among donors. multiple projects. (8) Risk analysis prepared as a basis for de- tailed contingency planning for changes in The net effect of these recommendations is to (a) the macro-environment; (b) the policy expand the list of actions that must be completed framework; and (c) key staff. As part of before loan or credit approval, making the prepara- the contingency planning, remedies should tion process for a development program even more have been defined for noncompliance xi SUMMARY OF MAIN POINTS with, or substantial deviations from, agree- (1) Donor agreements reached on pooling of ments. resources. (9) Provision of the correct profile of staff and (2) Financial incentives included for good per- adequate resources (including outside financ- formance. ing and internal budgets) for program su- (3) Harmonization of procedures for financial pervision. management and procurement (likely to be a medium-to-long-term goal). The following are other desirable but not essen- tial conditions for commitment of funds: xii CHAPTER I INTRODUCTION SITUATION agriculture sector in Zambia at one point there were over 145 separate projects. The Primary enrollments in Sub-Saharan Africa have not situation was similar for the education sec- kept pace with population growth. The gross enroll- tor in Mozambique, as explained in Box 1.1. ment ratio in primary education declined from 78 Project assistance is often characterized by percent in 1980 to 72 percent in 1990 before recov- the lack of use, and the lack of development, ering to 74 percent in 1995. (Verspoor:17) In the of government institutions and procedures. 1980s spending on education per inhabitant de- Each donor agency tends to follow separate creased by a catastrophic 65 percent in Sub-Saharan procedures for the implementation of their Africa (UNICEF: 13). At the current rate, nine coun- projects. For the most part each project re- tries are projected to have fewer than half the eligible quires the establishment of a separate or- children in primary school by 2015, including Ethio- ganization (project implementation units) pia, Mozambique, Angola, and Sierra Leone (Oxfam: to execute the project in view of weak ca- 57). Three-fourths of the world's out-of-school chil- pacity within normal government struc- dren by then will be in Sub-Saharan Africa. tures. This disperses government capacity over many small units (Harrold: 3-4). The net result may well be a duplication of ef- PROJECT ASSISTANCE forts (Cassels: 8-9). The concentration of at- tention and funds on specific projects also The impact of development assistance generally has means myopia: lack of an overall view of been disappointing. A study in 1994 by the Bank's the sector as a whole, and lack of attention Operations Evaluation Department found that 60 to overall policies, institutional and eco- percent of all Bank projects in Africa in 1992 were nomic environments, and constraints un- not meeting their objectives. More broadly, project der which projects must operate (Cassels: assistance has come under increasing criticism by 7). both donors and recipients. Project assistance in (b) External assistance tends to be donor-driven. Africa has been criticized as (a) fragmented, (b) Donor agencies typically have their own sets donor-driven, and (c) having weak impact on solv- of priorities and kinds of components they ing basic problems at the sectoral level. These three would most like to finance. Donors often topics are discussed below. foist these agendas upon the recipients. The assistance may be based on inconsistent vi- (a) Project assistance has tended to be frag- sions (Jones: 24) and conflicts may arise be- mented. Many countries host a multiplic- tween the different approaches. Donor ity of donor-financed projects. In the dominance with parochial agendas can re- 1 INTRODUCTION Box 1.1I Multiple Donors for Education in Mozambique Prior& extenal assistance to the Ministry of Education was provided under more than 150 different pj ects and subprojects by more than 16 countries, 6 UN agencies, 3 major multilateral financing institutions (IDA, African Development Bank ,and European Union), and a large number of local and international NGOs operating throughout the country. The Government was simply unable to moni- i torthis large number iof projects. In addition, there were serious inequities under these projects in fresource allocation to schools, districts and provinces, and more important, resources were often not geared toward urgent priorities. In addition, the numerous project implementation units and inde- pedent parallel Activities such as audits, supervision, etc. drew heavily on the limited Government cagpacity,therey rediucin gthe Government's resources to undertake their administrative function. Wac c duc ::R?t ; ff i g: rnme E 0 c un: This was&compounded by the use of different procedures and financial management systems by do- nors mi parallel operatioons. Source:* Mozmbique education case study. sult in the distortion of spending priorities budgets. The fragmentation strains govern- by subsectors and between types of financ- ment systems and personnel. (Peters and ing (e.g., development vs. recurrent spend- Chao: 180-81). It allows shifts in government ing). Donor projects can also tend to be spending to non-priority items through overly designed and overly complicated in "fungability." (Jones: 4). a misguided search for perfection or to meet the developed-country standards of the con- tributing agency. This can result in incon- PROGRAM ASSISTANCE sistent and inequitable standards for an enclave within the education system. Program assistance (i.e., support for overall programs Projects with high standards (referred to rather than more specific projects, often on a fast- sometimes as "gold-plated") can be costly disbursing basis) has proved to be helpful in par- or impossible to sustain in poorer countries. ticular circumstances, such as emergencies. However, Donor-driven projects also tend to be in- the impact has been limited on sector-wide prob- flexible when faced with changed circum- lems. There are two main types of program assis- stances (Cassels: 8-9). tance, support for structural adjustment and sectoral (c) Despite successes in individual projects, the adjustment, as follows: consequences of project-based assistance have been weak performance and impact at (a) Structural adjustment operations (or the sectoral level. (Jones: 4) Harrold (3-4) "SALs") have been able to achieve large, refers to "islands of success in a sea of fail- rapid injections of money into countries in ure." The failures can be attributed in large crisis. Funds are disbursed in tranches in part to the characteristics of projects. Myo- response to compliance with policy condi- pic, enclave-type approaches ignore the lack tions. Structural adjustment has been par- of coherent sector policies, systems and ticularly effective in improving balance of 2 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA payments (Peters and Chao: 180; Cassels: THE DEVELOPMENT OF 9). However, structural adjustment opera- SECTOR-WIDE APPROACHES3 tions typically do not get deeply enough into sectoral issues (Harrold 3-4). They lack long- The Roots of Sector Investment Programs term horizons, and do not usually control (SIPs) how funds are spent within sectors. Conse- quently, they have been less effective in pro- Dissatisfaction with project and program approaches moting long term sectoral objectives (Peters led to the development of innovations to improve and Chao: 180-1). the impact of development assistance on the sector (b) Sectoral adjustment operations' (or as a whole. The major development for the Africa "Secals") were a phenomenon largely in re- Region was the introduction of the "Sector Invest- sponse to the crisis of the 1980s. Most Secals ment Program", or "SIP," in 1994. Peter Harrold has took place between 1985 and 1995. Secals written the definitive explanation of SIPs in his work: have had mixed success. The sectoral adjust- "The Broad Sector Approach to Investment Lend- ment operation in Guinea showed that un- ing" (1995); Andrew Cassels has prepared the best der certain conditions (specifically, strong set of guidelines on sector programs: "A Guide to consensus and government support) the Sector-Wide Approaches for Health Development: lending instrument could lead to increased Concepts, Issues and Working Arrangements" (1997). expenditures for education. More recently, SIPs draw on earlier experiences outside the the Uganda Education Sector Operation Africa region. First, they include elements from more (February 1998) has had good success in traditional "sector loans', or sector investment and supporting the government's drive for uni- maintenance loans. These (a) focused on policy versal primary education. However, as in- changes, (b) financed a time slice of an investment dicated by other operations2 increased program, and (c) delegated selection and implemen- financing for the sector does not necessar- tation of subprojects to intermediary organizations ily translate into better output or products. within agreed criteria and procedures.4 The Tanza- As Cassels (p. 9) stated for the health sec- nia Integrated Roads Project in particular followed tor, "There is little to be gained by merely this pattern. Second, SIPs are patterned after inno- guaranteeing funds for an inadequate and vative operations in the South Asia region in which inefficient health system." The weakness of donors agreed to support a common program to raise sector adjustment operations is that they expenditure in particular social sectors. The Paki- focused almost exclusively on increased fi- stan Social Action Program (SAP) is an example of nance for the sector, and did not get deeply coverage of multiple subsectors, health, education, enough into programs for improving sec- and water supply. The Bangladesh Health Program tor outputs and performance. targets one sector. Sector adjustment operations are similar to structural adjustment inasmuch as they disburse funds in tranches on the basis of compliance with policy conditions. They differ in scope, focusing on one sector rather the economy as a whole. 2 Examples include the Ghana education sector adjustment credits, "EdSAC". 3 Terminology: The working group under the Special Program for Africa has adopted the term "sector program" to de- scribe the genre. This replaces the terms Sector-wide Approach ("SWAP"), Sector Investment Program ("SIP"), Sector Devel- opment Programs (SDPs), etc. However, this review uses the terms "sector-wide approach", "sector-wide program" and "sector program" interchangeably. See Thomas (1994) and Johanson (1985). 3 INTRODUCTION SIP Characteristics (b) strategy of measures to achieve policy objectives over the medium term (about The "Sector Investment Program" is not a lending 5 years); and translated into (c) a pro- instrument per se. It is a comprehensive approach gram of specific interventions in the near that can be supported by an array of lending instru- term (2-3 years). ments, including specific investment loans (SILs), (3) Expenditure Framework sector investment and maintenance loans (SIMs), > Overall expenditure program, including and-more recently-adaptable program loans definition of feasible intersectoral allo- (APLs.) Table 1.1 shows the types of lending instru- cations and the resource envelope ments used for the eight SIP cases presented later in ; Intrasectoral spending plan, derived from part II of this review. program priorities The main rationale of for the SIP is to address (4) Management systems and capacity building the weaknesses of projects and achieve greater over- o Common implementation structures all impact with development assistance. The presup- and procedures (harmonization of do- position is that sectoral goals can be achieved better nor procedures) through a sector-wide approach and nationally de- o. Use and strengthening of government in- fined policies, strategies, and budgets rather than a stitutions, procedures, and staff (rather series of specific projects (Cassels: 12). than setting up parallel systems and us- Different reviewers have compiled lists that iden- ing external technical assistance) tify different characteristics of SIPs (Harrold: 6; Jones: 8-9; Cassels: 11; EU: 3) In synthesis, there seem to Essentially, sector-wide approaches such as the be four main features, as follows: SIP emphasize process rather than products. They emphasize processes by which policies are translated (1) Partnership into strategies and programs, then into expenditure o Local stakeholders in charge-program plans that make sense in a national and long-term directed by government context, followed by joint reviews of actual perfor- -c All key donors sign on to the program mance against the plans, and adjustments as appro- • Coordination of donors by government priate. Sector-wide approaches get away from the > Broad consultation with stakeholders idea of finite stages, such as a design stage followed (2) Comprehensive sector policy framework by a full-fledged investment program (Cassels: 13). • Sector-wide scope, covering all relevant The emphasis shifts from meeting ex ante standards areas, policies, programs, and projects. to tracking improvements over time (Grindle: 5). • Based on an (a) overall policy for the Sector programs do not define everything in advance sector (principles and objectives); as does a project. Therefore the processes-especially TABLE 1.1 Case Studies by lype of Lending Instrument Lenin Istument SPEape Specific Investment Loan (SIL) Ethiopia Health; Ghana Health; Senegal Health Sector Investment & Maintenance Loan (SIM) Zambia Health; Ethiopia Education Adjustable Program Loan (APL) Gambia Education; Zambia Education Technical Assistance Loan (TAL) Mozambique Education 4 EDUCATION AND HEALTHI IN SUB-SAHARAN AFRICA the instruments for dialogue and agreement- for improving assistance to the poorest countries become of overriding importance. As noted in sev- in the health sector. eral of the cases, e.g., Ghana, a sector-wide approach Within the Bank a growing number of SIPs have does not have the security of a traditional project been approved and the pipeline is populated with where content and quantities are defined in advance. intentions to do more. Most SIPs have been used in Instead, the security must be implicit in the proce- low-income, aid-dependent countries with multiple dures by which decisions are made during imple- active donors (Zambia, Mozambique, and Ethiopia mentation. mainly). The social sectors account for about half of all SIPs. Within this context the health sector has led in the development of sector-wide approaches INNOVATIONS IN SIPs (for example, the Zambia health sector program was regarded as a SIP retroactively). Increasingly, SIPs There is much new in this approach, both in abso- are being used in the education sector, including lute terms and relative emphasis, as follows: Ethiopia, The Gambia, Mozambique, and Zambia. Problems have also been experienced in the devel- (a) Clear linkages are established among analy- opment and implementation of sector-wide ap- sis, policydevelopment, strategic plans, pro- proaches. These include client policy changes grams, budgets, and implementation inconsistent with the agreed framework (Zambia through annual reviews (Peters and Chao). health, possibly Ethiopia); bilateral financing incon- (b) Policy development is not a one-off exer- sistent with the agreed framework (Ghana health); cise, but a dynamic process to be updated difficulties of procedures for procurement and fi- and renewed as circumstances become nancial management (nearly all countries.) clearer or change (Cassels: 35). (c) Explicit connections are forged with the macroeconomic framework. Resource allo- PURPOSE OF THE REVIEW cation is derived from an overall expendi- ture framework. It is still too early to learn much from implementa- (d) Donor procedures are harmonized. tion experience, but in view of the number of (e) Rather than bypassing normal government sector-wide operations already in existence, the num- institutions and processes, SIPs aim at us- ber of new ones planned, and their potential it is ing and improving government structures nonetheless important to seek some tentative con- and procedures for such functions as pro- clusions. Of necessity, these lessons will have more curement, financial management, and ac- to do with design than implementation. Therefore, counting. a review was conducted in the second half of 1999 of experience to date, mainly in the Bank's social sec- Sector-wide approaches have attracted a wide tor of health and education. The intended audience range of interest. Many donors, particularly Euro- of the review is Bank operational staff in the educa- pean bilateral assistance agencies, see the approach tion sector of the Africa region. The review sought potentially as a major improvement over project to answer the question: how should a sector pro- lending. The Nordic countries, the Netherlands, and gram be done? What does doing a sector program the United Kingdom have been instrumental in "right" look like? studying and promoting the approach. In addition The review used three sources of information. the EU-convened conferences on sector-wide ap- First, the myriad studies on sector programs were proaches and the U.N. Special Program for Africa reviewed. (See bibliography for works consulted.) adopted sector-wide approaches as a main theme Second, interviews were conducted with task team 5 INTRODUCTION TABLE 1.2 Case Studies in the Review Health Sectri XEd ticon Sector Ethiopia Health Ethiopia Education Zambia Health Zambia Education Ghana Health Gambia Education Senegal Health Mozambique Education These appear in Part II of the review. leaders and other knowledgeable persons within the which requires (a) adopting an appropriate Bank about sector-wide programs. (See list in An- scope, (b) basing it on strong analytical nex 1 of World Bank staff interviewed.) Third, eight work, (c) consultingwith stakeholders about case studies of health and education projects were priorities, and (d) continuing the policy de- prepared, as shown in Table 1.2. velopment process during implementation. (Chapter 3) c; Prepare an overall expenditure framework FINDINGS that (a) defines appropriate intersectoral al- locations, a feasible resource envelope, and Based on the findings of the review, a sector pro- (b) ensures appropriate allocations within gram should: the sector; (Chapter 4) and Establish management arrangements that .. Meet the preconditions before starting pro- (a) analyze and build institutional capacity, gram development. (Chapter 1) (b) concentrate on effective monitoring and > Establish an effective collaborative pro- evaluation, and (c) set up appropriate finan- cess-which requires (a) developing donor- cial mechanisms. (Chapter 5) government partnerships, (b) following the national leadership, and (c) forging donor These points are discussed in sequence below, coordination. (Chapter 2) followed by conclusions and recommendations > Establish a proper policy framework- (Chapter 6). 6 CHAPTER 2 MEETING THE PRECONDITIONS TO START THE PROCESS A key question is: where are sector-wide approaches is unlikely that a long term program can be appropriate? Where can they be used? In what types developed or sustained in a context of rap- of countries is this approach most suitable? The early idly changing regimes. The importance of development of SIPs stressed the importance of ownership and capacity limits the applica- meeting various, extensive pre-conditions. However, tion of sector-wide approaches to stable concern has now shifted from "preconditions" to a environments (Jespersen: 3). As stated in more flexible approach based on a common vision the Ghana health case," A sector-wide ap- by stakeholders with no particular blueprint for proach cannot be done in a 'stop and go' implementation arrangements (Grindle: 1). context.' It is important to distinguish between precon- * Commitment. Sector-wide approaches are ditions to start the development of a sector program, defined by intent rather than pre-existing and preconditions for approval offinancing.' A ba- achievements. (Cassels: 14) The main re- sic precondition for starting a sector-wide approach quirements are intent to take an integrated is dissatisfaction with current conditions, e.g., the approach and commitment to a collabora- ineffectiveness of project lending, the system is in tive process (EU: 7). This was done quite crisis. Beyond this, preconditions for starting to de- clearly in two of the case studies: Zambia velop a sector program boil down to stability, com- Health and Ethiopia Education. mitment, and minimum institutional capacity: > Institutional Capacity. The country must have at least the minimum level of institu- > Stability. This means two things: (1) Macro- tional capacity to handle the development economic stability. There is consensus that and implementation of the program. This it makes little sense to develop sector pro- is a relative rather than normative standard. grams in the absence of a suitable macro- Of course, institutional capacity can and economic framework, i.e., manageable should be developed further during the pro- budget deficits, low inflation rates (Harrold: gram, but some minimum basic capacity 20-2 1). The reason is that sector programs must exist to enable the start of a successful need adequate, stable financing. These re- process. As Harrold stated (22), "There is a quirements cannot be met under conditions tension between requiring good capacity to of high inflation or excess deficit spending exist as a basis for a SIP, and using the SIP (Okidegbe: 3); and (2) Political stability. It process to develop this capacity." Preconditions for financing a sector program are presented in Chapter 7, Conclusions and Recommendations. 7 MEETING THE PRECONDITIONS TO START THE PROCESS These three criteria suggest that sector-wide For example, the failure to develop a health sector approaches are not appropriate in all countries. They program in Cote d'Ivoire can be attributed to would not be appropriate where political and inadequate government commitment. Some economic instability have not been achieved (e.g., observers would go so far as to suggest that sector in conflict situations or perhaps in recent post- programs are only appropriate for countries with conflict countries). They should be avoided where solid implementation capacity and that only a few there is insufficient interest by the client in taking countries are therefore ripe for sector-wide leadership of the process (Peters and Chao: 180). approaches. 8 CHAPTER 3 ESTABLISHING A COLLABORATIVE PROCESS Establishing an effective collaborative process re- scrutinized by all parties. Once agreement is quires (a) developing donor-government partner- reached, all parties assume collective responsibil- ships, (b) following the national leadership, and (c) ity for subsequent achievements and failures forging donor coordination. These topics are pre- (Cassels: 13). sented sequentially below. Partnerships can be threatened by lack of com- munications (EU: 13), lack of transparency and clar- ity (Peters and Chao: 186; Jespersen: 4). One of the DEVELOPING DONOR-GOVERNMENT most significant barriers to effective partnership is PARTNERSHIPS frequent conflicts and changes of personnel (Peters and Chao 190). It seems ironic, but almost axiom- A sector-wide approach requires a fundamental atic, that once a sector program has been approved- change in the way organizations behave and relate usually involving major institutional and policy to each other (Peters and Chao: 180). It involves both reforms-the key personnel on the government or adoption of a partnership between government and donor side change. These changes disrupt program donor agencies and close coordination among the continuity and explain slow initial implementation donors. Some observers feel that success in sector in several cases (e.g., The Gambia education). programs ultimately has more to do with the char- Experiences of those involved in the process state acter of the partnership than the technical sound- clearly that it takes time to build partnerships. Sta- ness of policies (Peters and Chao: 186). bility on both donor and government sides is im- Trust, mechanisms for negotiations, and flex- portant. Contingency plans should be made for ibility by participants are key characteristics of staffing changes, such as by broadening the consul- successful partnerships. First, trust plays an impor- tation process to ensure a wide range of people are tant role. Sector approaches delegate a significant familiar with the content and processes of the sec- degree of authority to the recipient country. The tor programs. donor trusts that the recipient will act in accor- Finally, it is essential to design appropriate fo- dance with agreed criteria and procedures. rums for dealing with problems (Peters and Chao: Openness is extremely important for building and 186). As noted in the Ghana case, it is highly im- maintaining trust. This clearly prevails in the Ghana portant to have a system in place through which the health program. In contrast, trust has been lost in views of all parties can be aired and disagreements the Zambia health program (See case studies). Ap- resolved. In the end it is not so important that dis- propriate mechanisms must be established for putes and differences occur as long as a process of discussion of issues and negotiation of solutions. mutual consultation is in place and methods have Give-and-take is an important requirement for suc- been agreed in advance on how to resolve disputes cess in partnerships. Decisions must be carefully and solve problems. 9 ESTABLISHING A COLLABORATIVE PROCESS USING NATIONAL LEADERSHIP TO BUILD fore, lead to resistance from those quarters. More OWNERSHIP AND SUPPORT broadly, sector-wide programs subject the govern- ment to greater external scrutiny. Issues that previ- Reviews by the Operations Evaluations Department ously were the sole prerogative of government get (OED) consistently point to the importance of na- placed on the agenda for open discussion. Authori- tional ownership and commitment in ensuring the tarian regimes could resist this tendency. success of development assistance (for example, the Finally, the exigencies of national leadership and 1994 OED review of 1992 performance.) One over- partnership need to be reconciled. It is not donors, riding aim of a sector-wide approach is to ensure acting in concert, imposing their agenda on govern- country ownership of the product (Harrold: 23). ment. Nor is it government authoritatively dictat- National leadership is one essential means to ensure ing terms to donors. The government is the final ownership of programs. (The other is broad con- arbiter, but all parties have rights and responsibili- sultation, discussed later.) ties (Cassels: 13). One recommendation from best Under a sector-wide approach national leader- practice is that these rights and mutual responsibili- ship (or sponsorship) is indispensable for the de- ties should be spelled out at the start in a "State- velopment of a program. The case of Zambia ment of Intent" adopted by all parties, and later in a education exemplifies this point (see case study). The "Code of Practice" (as was done in the Ghana health process of developing a sector program foundered case). in the mid-1990s until a strong, new minister of education took leadership of the process. Then de- velopments fell into place. FORGING DONOR COORDINATION: WORKING Some of the findings on leadership include the TOGETHER UNDER GOVERNMENT LEADERSHIP following points: First, there is a tendency for lead- ership and ownership to be vested in a small group Until donors learn to work together external assis- of individuals (Jespersen: 4) In most cases SIPs are tance cannot be fully effective. Sector-wide ap- driven by a few key proponents in the sectoral of- proaches ensure that all participants share one fice. The lack of broad support can lead to imple- common set of aims and tell a consistent story. The mentation problems or delays (Jones: 10, 22; Utz: essence of a sector-wide approach is that donors give 7.) Another potential problem is lack of involvement up the right to select which projects to finance in by central ministries, such as the finance ministry, exchange for a voice in the process of developing in the process of formulating the sector program the broad sectoral strategy. Donor-specific project (Jones: 22.) Furthermore, the level at which owner- planning is replaced by negotiating how resources ship resides is important. For example, the whole are spent within the sector. A joint review of sector cabinet approved the Bangladesh health program, performance replaces the evaluation of discrete ensuring broad support. If the cabinet or parliament projects (Cassels: 12). does not approve the program, the program may be Donor coordination means two things: (a) agree- in for tough sledding during implementation. It is ment on a common program; and (b) adoption of also important for participants to have clearly in common procedures. Each is explained separately mind in advance which groups stand to gain or lose below. from the sector-wide approach, as this affects the degree of political support and their viability (Cassels: 29-30). A sector-wide program tends to strengthen Common Program the power of senior policymakers and reformers. It decreases the power of individual project managers The adoption of a common, shared program ensures and other donor-funded fiefdoms and may, there- that all participants aim at the same objectives and 10 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA means, even though they maybe financing different Harmonization has proved easiest to achieve parts. This benefits all parties by eliminating dupli- in four areas: (a) reporting formats and timing, cation and avoiding parallel, often contradictory, (b) common performance indicators, (c) joint mis- donor-driven designs (Harrold: 12). sions, and (d) procedures and norms for technical Signing on to a common program has several assistance. important implications for the partners. First, it Harmonization is most difficult to achieve in means exclusion, that is, agreement by donors not (a) procurement and (b) financial management. to finance expenditures outside the agreed frame- Under procurement, the "rules of origin" may pre- work and for governments not to accept financing vent multilateral agencies from cooperating. For of things that fall outside the framework (Jones: 24). example, the membership of the World Bank and The case studies show examples in which exclusion the African Development Bank are not congruent was not observed by government (e.g., urban hos- and, consequently, common eligibility rules cannot pitals in the Ghana health program). It is understand- be followed. In practice, several donors allege that ably difficult for a government to turn down grant harmonization in practice means following the stan- financing of a project with a willing donor, but dards of the most restrictive donor, or bilateral agen- concentration of resources on agreed priorities de- cies agreeing to accept the standard procedures of mands it. The exclusive nature of the agreed pro- multilateral organizations such as the World Bank gram has to be recognized explicitly in advance. Sec- (Grindle: 7-8). Financial management is particu- ond, adoption of a common program may mean larly sensitive for all donors. It involves the greatest retrofitting or phasing out existing projects that are risk of waste or misapplication of funds. It is also inconsistent with the program (Utz: 8). Third, it re- where the gulf between requirements and actual quires that all participants be completely open and practice is the widest: between requirements for do not try to conceal activities (Grindle: 7-8). It also strong accountability by donors and the practices means that donors are able to assure the government of relatively weak national systems of financial on the timing and levels of their support. This has management. proved to be problematic. Finally, success is no longer Harmonization of procedures such as procure- the achievements of particular projects or particu- ment and financial management are not usually sec- lar donors; it is shared by all participants for the sector tor-specific. Much of the work on harmonization as a whole. could therefore be done beyond the sectoral level (Jespersen: 8; Jones: 34, 41). The parallel develop- ment of sector programs in education and health Common Procedures (or "Harmonization") in Ethiopia, with education approximately six months ahead of health, allowed the health sector Adoption of common procedures has been one of to use generic procedures developed for education. the main aims, and one of the main obstacles, for (See case studies.) The advice from best practice is sector programs (Grindle: 5). Adoption of common that central authorities should be in charge of de- procedures requires donors to compromise on their veloping common procedures applicable to a range own internal procedures, which has proved difficult of sectors. (see the Ghana case.) The objective of common pro- Several factors work against harmonization (Pe- cedures is to reduce the administrative burden placed ters and Chao: 184). These include "attribution", or on government by different procedures and from the need for donors to be associated with specific donor to donor. The benefits of harmonization are inputs or components (i.e., "showing the flag.") Nar- better-quality information, more timely information, row commercial interests, such as tied procurement, reduced duplication and waste, and release of time also run counter to the adoption of common proce- of government staff (Jespersen: 8). dures (Harrold: 12). Resentment and jealousy often 11 ESTIABLISHING A COLLABORATIVE PROCESS exist between donors, for example at the real or imag- transaction costs are high. In both the Ethiopia and ined dominance by certain donors including the Zambia education cases, the task managers stressed Bank. Donors must also work through the loss of that one cannot do too much donor coordination. direct control over the use of their funds. Other ob- Harrold (12) suggested that there should be burden stacles are the inability of some donors to finance sharing in view of the high administrative costs of recurrent costs, and their inability or unwillingness coordination. This was in fact done in the case of to change their practices to accommodate new joint the Bangladesh health program and the Pakistan SAP methods. Finally, there is the natural tendency of by allocating administrative funds explicitly for the donors not to get overly involved in components that purpose of donor coordination units. These helped they do not finance. There is a natural reluctance prevent an endless flow of paper. for donors not to criticize others. In the Zambia (b) Mechanisms for coordination. Several instru- education case, questionable assistance by one Eu- ments are cited in the literature and the case studies ropean bilateral donor was tolerated until the sec- as means of facilitating cooperation among donors. tor approach brought all assistance under external scrutiny and discussion. Its low cost-effectiveness was (1) "Statement of Intent"-these serve to set the immediately questioned. parameters for the sector approach and do- nor coordination at an early stage. State- ments of intent ensure that all parties Instruments for Coordination (government and donors) have the same vi- sion of what is intended and expectations. (a) Lead agency. One way to achieve coordination is It reduces confusion during program devel- for donors or the client to appoint a "lead donor." opment (Cassels: 52). The role of the lead donor is to ensure an open flow (2) "Collaborative Work Programs-set out the of communication among the donors, call meetings, tasks, sequence and responsibilities. establish agendas, and follow through on actions. (3) Joint missions-in which multiple donors Jones (25) has emphasized the importance of a lead participate to accomplish common terms of donor for reasons of efficiency. Having a lead agency reference at the same time in the country. is not essential, but it can make communications (4) Joint aide memoires-in which joint mis- more efficient, particularly for the government. For sions adopt a common set of findings, con- example, a lead agency can reduce the transaction clusions, and recommendations. costs for the government in dealing with multiple (5) "Memorandum of Understanding"-these donors. If a lead agency is selected, best practice sug- are usually agreed upon at the stage of com- gests that the role, responsibility, and authority of mitment of funds (and are often patterned the lead donor be defined in advance and agreed on after the Bank's Development Credit Agree- by all cooperating partners (see, for example, the ments.) They cover topics including: (a) fi- Mozambique education and Ethiopia education nancing-purposes for use of funds; eligible cases.) The World Bank does not need to play the expenditures, commitments on levels, (b) role of the lead donor (see the Senegal health case.) disbursements-how donor funds will be In fact, in only three in the eight cases reviewed was channeled, common accounts, pooling, re- the Bank was the lead donor. One of the issues in sponsibility for management, readiness cri- having a lead donor is that few donors appear able teria government eligibility for pooled funds, or willing to delegate fully to the lead agency (c) procurement, (d) negotiations, consul- (Jespersen: 9). tation, and information exchange-mecha- It is clear from experience that the lead donor is nisms for negotiation when circumstances likely to incur a heavy administrative burden. The change, timing of government reports, joint 12 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA reviews, and exchange of information ment has been controversial2 and has been (Cassels: 53-55). slow to gain acceptance. A "Code of Practice" (6) "Code of Practice"(Cassels: 55) covering such is not a guide for day-to-day decisions, but it topics as open sharing of information, use of can provide a useful reference in cases of dis- joint missions, and use of external technical agreements. It is one element in the mecha- assistance only as an exception. This instru- nism for resolving disagreements. 2 For example, one early version of a code of practice stipulated that local and external technical assistance should be paid the same. 13 CHAPTER 4 DEVELOPING A POLICY FRAMEWORK Apolicyframework is the set of policies used bythe tation of sector policies (Jones: 20; Harrold: 8; government to direct the sector. The process of de- Cassels: 36). veloping a sector program should start, as Cassells Some of the findings of the review suggest that (37) wrote, by setting out the big picture about de- reaching agreement on the sector policy framework sirable characteristics and essential features of sec- is more likely the extent to which the sector is in cri- tor delivery. The aim is to establish a minimum set sis, the narrower the range of institutions involved, of clear principles for development of the sector upon the fewer the donors, and the less contentious the which strategy can be based (Harrold: 8). topics included (e.g., basic health or education.) Three levels of definition are involved in a good Agreement on the policy framework inevitably takes policy framework: time and involves compromises on the part of do- nors and governments alike. Donors should resist • Policy (overall goals and principles) pressures to accelerate the process (Jones: 29, 38). • Strategy (objectives and means to achieve Four main requirements exist for the establish- the overall goals, usually with a time frame ment of a workable policy framework: (a) defini- of 5-1O years); and tion of appropriate program scope; (b) strong + Program, a set of specific measures to imple- analytical underpinnings; (c) consultation with stake- ment the strategy over the short to medium holders; and (d) a flexible, ongoing process. Each is term. explained in turn below. Development of the policy framework typically follows the progression of moving from the general REQUIREMENT 1: to the specific, i.e., from principles to strategy to pro- DEFINITION OF APPROPRIATE PROGRAM SCOPE gram. The case studies clearly depict this sequence, including Ethiopia education that moved from over- An early key decision in the planning process is to all goals to a program action plan (PAP). The Ghana define the scope of the sector for which the program health project also progressed from overall principles will be prepared. According to Harrold (6) the sec- into a focused program of work (POW). The Senegal tor should be comprehensive to avoid fragmenta- health project included a similar progression, as tion of planning and implementation that could shown in Box 4.1. reduce efficiency and output. By definition, a sec- One of the main purposes of a policy frame- tor-wide approach should avoid being insular and work is to provide a basis for establishing priorities dealing only with certain enclaves. It should deal with for public expenditures within an overall resource relationships between subsectors and components envelope. It provides a reference for the extent to of the system, and between recurrent and capital ex- which expenditure programs support the implemen- penditures. 15 DEVELOPING A POLICY FRAMEWORK Box 4.1 Prora D e eloptin Senegal Helth (1) The National Task Fore first agreed on ai action,plan for the design of the program. (2) The sec- ond step was to undertake a series of studiesi toassess human resources, health financing, hospital re- form, primary health care, and cost recovery. Donor fiuns were readily availble to finance these studies. (3) Third, based on the findings the Ta Force developed a "ng rm Strategic Vision for Health Development." (4) Fourth, thesk Frce then developed at-year National Health Plan, which identified critical priorities and impementation mechanisms with technical support from multilateral and bilateral donors and siing extensiv consultations with stakeholders. Govern- ment ownership of the deign procs was srng withMtry of Health (MO(-H) being the driving force behind the process. (5) The long-term pln led then to the preparation of a "Five-Year Action Plan" that spelled out immnediate priorities aninvestment requirements. (6) The Ministers of Health and Finance convened a oundtabley of donors at which the Plan w asreviwed bIy donors and pledges were made for the financing of thePln. This resulted in a wel- conceived financing plan, including both national and external sources. (7) Program 3appraisal came, right after the roundtable. Key pro- gram documents (strateg fameok /long-term plan jand imedium-term expenditure program) were reviewed and commen t i on by donors at regur intervals in the program design process and officially endorsed ilat theronae.The erefew geentsof a substaitive nature. Differ- ences centered mainly on administrative andfinancialprocedres. Source: Senegal health case studyI One suggested criterion for the definition of in education: inadequate consensus on policies at sectoral scope (Harrold: 7) is whether the program higher levels and weak capacity to manage all covers the most significant expenditures, i.e., in- subsectors. There is not much agreement interna- cludes all important sector-related expenditures. tionally on appropriate policies for upper levels of However, completeness (i.e., avoidance of fragmen- the education system, particularly higher education tation) has to be balanced with institutional feasi- and vocational education and training. Inclusion of bility. Jones (17-18) suggests that the key question these subsectors in the scope of sector programs in deciding scope is whether the program is linked could well delay progress on other priority areas such to a clear budget entity for financial management. as basic education. Another problem concerns lim- In effect, the sector program becomes a ministerial ited government capacity, which would suggest lim- program. What should be avoided is a program that iting the scope of programs. A recent review of SIPs is based on cross-cutting themes, such as women in in Africa for all sectors found them to be character- development or even nutrition (Cassels: 20). Such ized by lack of sector-wide coverage. Zambia educa- thematic programs cut across too many adminis- tion (BESSIP) is an example of a decision to limit trative boundaries to be readily implementable. coverage, as shown in Box 4.2. Harrold (8) wrote that an education sector pro- Focusing on one subsector, e.g., primary, has gram that failed to include tertiary education could appeal from the viewpoint of designing a manage- not be regarded as a sector program, nor could a able program. However, dealing with one subsector program that only included tertiary education. How- alone also has potential disadvantages, including: (1) ever, comprehensive scope confronts two problems neglect of intersectoral resource allocations leading 16 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA to critical imbalances between major spending cat- with only one subsector. Similarly, if it is not pos- egories; and (2) concentration of donor funds and sible to adopt a sector-wide investment program, subsequent unsustainable financing for one level one must nevertheless monitor the overall expen- (Cassels: 19; Peters and Chao: 185-86). diture framework and trackfunds at the sector level In this context it is helpful to distinguish be- to ensure reasonable intrasectoral allocations (Pe- tween a sector-wide scope for analytical purposes ters and Chao: 186; Cassels: 19). The reason is to and for investment purposes. For analytical purposes, avoid "fungability', i.e., to prevent external funds a broad definition of the sector is important as a from freeing up resources for allocation to activi- context for defining a coherent framework for sec- ties of low overall priority. This was not done in the tor policy objectives. This provides an overall um- Zambia education case. brella for more specific investment work. For investment purposes, it may be appropriate to de- fine the sector more narrowly. The APL instrument REQUIREMENT 2: provides Bank staff with the opportunity to support STRONG ANALYTICAL UNDERPINNINGS a series of subsector programs over time within an agreed sector policy and financial framework. The A sector-wide program needs to be built on the Mozambique education case exemplifies a sector- basis of thorough sector analysis, including identi- wide analysis followed by investment concentrating fication of priority issues, causes and consideration on basic education. of alternative solutions and strategies. Quality sec- The conclusion is that a broad sector policy tor work is a good predictor of success of a sector framework should be developed for the sector as a program. Harrold referred to Mozambique health whole in all cases to ensure that the parts of the sys- as a sector program emerging from good sector work. tem are properly placed and dimensioned, even Another example, drawn from the case on Ethiopia though the investment program may necessarily deal education, is shown in Box 4.3. BOX 4.2 Deciding on Scope in the Zambia Education Program The development of this program went through several stages of reduction in scope to achieve a final definition of the "sector," or in this case, "sub-sector." Initially an attempt was made at developing a comprehensive Education Sector Investment Program (ESIP), coordinated by an ESIP Secretariat. Higher education was excluded from the beginning on the basis that it was an area of lower priority for new investment, and the intractable nature of the problems at that level. Even without higher education ESIP still included four ministries, (i) the Ministry of Education; (ii) Science Technology and Vocational Training; (iii)Youth, Sport and Child Development, and (iv) Community Develop- ment and Social Services. In September 1997 the Government agreed to divide its program into two financing packages, one for basic education (BESSIP) and another for training (TSSIP)-to be started in about three years. Several agencies are nevertheless involved in BESSIP, including the Ministry of Education, The Public Welfare Assistance Scheme, and a Micro-Projects Unit attached to the Ministry of Finance and Economic Development that will administer community-implemented school con- struction activities. Source: Zambia education case study. 17 DEVELOPING A POLICY FRAMEWORK BO0X 4.3 Song 0Analytical Undpinni g for ihe Edcadtion pJogram The high level of sector analysis was one of the reasons for Bank acceptance of the sector-wide ap- proach in the education setor in. Ethiopia. Annual epublic xpenditure reviews and a social sector expendliture review tere available. In particular, the 1997 public expenditure review by the Bank established a medium-term expenditure framework. The bulk of the analysis that preceded the preparation of the Program was produced and facilitated by a Policy and Humani Resources Devel- opment (PHRD) grant and executed by the Government. The studies devloped by the project gn- erated primary data through household, institutional, and community surveys and combined this w ith secon:dary datafromprevious studies. The majority of the wokwas arried out by local staff and consultants. Nine separate studies were produced, includig access to and supply of educational facilities; demand and sup of educational manpower;; private and social returns to education; demograic analysis and population projections; household demand for schooling; the role of NGOs and the private sector in service delivery; costs and financing of education; commuunity con- sultation and participation; and cost eftfetiveness of k educational inputs. In addition, the Bank's Task Team Leadr spent considerable time with other donors to assemble analyes done by other agencies. In particular, USAID, the EL U (on higher education) and Swedish International Develop- ment Cooperation Agency (SIDA) (cost effectlveness; of difirent tyes of school construction) had significant studies and analyses that had not yet been widely disseminated. Soure Ethiopia e"ductin case study. This review found that much of the sector analy- Surely sector studies can be done later as a basis for sis in the cases was ad hoc and not subject to high refinement and amendment of policies. This is cor- standards of quality assurance. Most sector work rect, but when the analysis occurs is still important. consisted of specific studies financed from project The analysis first has to provide a basis for initial preparation funds and identified after the broad broad choices of priorities and strategies on which policy framework was already defined. These stud- funds will be expended. If mistakes are made in strat- ies typically were not subject to rigorous quality re- egy, misallocation of funds inevitably result. The lack views. The Task Team Leader or local preparation of broad, rigorous analysis of issues and alternatives leader were the ultimate clients for the studies. Staff at the start of program development is a cause for noted that locally conducted sector studies for Zam- serious concern about the validity of programs. bia education were of poor quality. In some cases Continued analysis is also needed during program the government did not even await the results of the implementation to inform the continuous develop- studies to inform its policies before forging ahead ment of policy. (Ethiopia health). In another extreme case, all needed sector analysis and expenditure reviews were done after the commitment of funds for the program REQUIREMENT 3: (Zambia health). CONSULTATION WITH STAKEHOLDERS This raises a question: since a sector-wide ap- proach is a process, why does the timing of the ana- A broad national involvement is necessary to develop lytical work matter? Analysis is a continuing process. a sector policy framework, including beneficiary feed- 18 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA back' as an input to policy development. The sensi- REQUIREMENT 4: tivity of policies adopted and their likely widespread A FLEXIBLE, ONGOING PROCESS impact on the population demands consultation. A OF POLICY DEVELOPMENT key to success is the vehicle used to generate national consensus on policies. Involvement of community What distinguishes sector-wide approaches from organizations is important for reaching a diversity earlier interventions is that policy development is of delivery approaches suited to the needs of people. not a one-off exercise, but a continuing process (Pe- This is especially important given the long-term (10- ters and Chao: 192). Typically, policy development to 15-year time horizon) involved in the policy frame- is seen as a discrete stage that produces a product- work (Jespersen: 5). a policy document-once and for all ( or at least for The findings of the review suggest some guide- the next five years.) The sector-wide approach stresses lines for consultation. First, the purposes of the that policy development is a continuous process. Al- consultation need to be differentiated. Consultation lowances must be made for refining, changing and to provide input into design for the policy frame- adapting policies based on in-depth studies, experi- work is quite different from the public relations that mentation and even international experience might be necessary to sell a program to the public (Cassels: 35-36; EU: 9). The initial policy statement that has already been adopted (Jones: 23; Cassels: is important, but it cannot be the last word. If too 31). It is the former that is discussed here. Second, much attention is paid to its development, time is it is important for the government to organize the wasted and reality gets replaced by documentation consultation, not donors. African ministers of edu- (EU: 9). Moreover, comprehensive analysis has lim- cation have noted a tendency of aid agencies to try its. Everything cannot be analyzed at once. It is easy to drive the process of strategy development, in- to miss some topics. For example, the Ghana health cluding consultation (EU: 9). Third, effective con- program is based on extensive analysis, but did not sultation is difficult and often does not get planned cover private health care and only now is beginning properly. There is a tendency to limit consultations to fill this gap. to the bureaucracy, as was done in the case of the Requirements for a strong process of ongoing Ethiopia education and health, rather than front- policy development include: (a) efforts to build lo- line workers and beneficiaries. The involvement of cal analytical capacity continuously; (b) experimen- civil organizations often appears ad hoc and tation among strategic alternatives and evaluation unstrategic (Jespersen: 5). Fourth, the timing of of the results; and (c) strong performance indica- consultations is important. It should not be done tors and monitoring of policy effectiveness so as to too early, for example, not before the definition of inform revisions and adjustments. These require- a concept paper and a structure for determining pri- ments, in turn, often place a priority on building orities (Harrold: 10), or some tentative priorities better data and information systems. and a resource envelope (Jones: 23). Harrold (8) Often some policy issues cannot be resolved be- singles out the Zambia agricultural SIP as particu- fore loan approval. More study and negotiation may larly exemplary for the wide consultations held. All be needed. The question is whether sufficient agree- eight cases prepared for this review involved con- ment exists between all parties on basic principles sultation with at least some stakeholders, but in most and policies to enable a successful start for the sector cases it was fairly limited. program. No absolute guideline can be given on what 'Caveat: it is not possible to include all private sector and NGO institutions (Harrold: 25). 19 DEVELOPING A POLICY FRAMEWORK is "sufficient agreement." This has to be decided by (Zambia education and Mozambique education), the authorities in each case. What helps is to be explicit first phase of the APL focuses on priority activities about the policy differences; to agree on the steps, for which there is consensus. Unresolved issues (e.g., process, and timetable by which the policy issues will vocational training and higher education) are de- be examined in depth; and to outline several courses ferred until later phases. Criteria, or "triggers", are of action if agreement is not reached. The Adaptable spelled out for moving from one phase to the next. Program Loan affords an excellent instrument to deal If consensus cannot be reached, subsequent phases with unresolved policy issues. As seen in several cases would be deferred or substantially reformulated. 20 CHAPTER 5 DESIGNING APPROPRIATE FINANCIAL PARAMETERS Sector approaches are distinguished from their pre- the social sector. As stated in the previous section, decessors by placing the sector within an appropri- the preparation of sectoral spending programs in- ate financial context. This involves two aspects: first, volve, or should be preceded by, dialogue with gov- ensuring appropriate intersectoral allocations and ernment and civil society about intersectoral defining a resource envelope, and second, ensuring priorities for public spending. correct allocations within the sector. In general, sector Appropriate allocations to the sector can be approaches seek increased overall funding for the achieved either by specifying a minimum relative sector and allocation of the increased financing to share of public resources for the sector, or by esti- priority activities. These two aspects are dealt with mating absolute amounts required. Earmarking pro- separately below. portions of government budget for the sector is almost invariably the approach used. All eight cases prepared for this review included targets for resource SETTING THE SECTOR WITHIN THE allocation, particularly Ethiopia education; MACROECONOMIC FRAMEWORK Mozambique education; Senegal health; and Zam- bia education. More broadly, sector programs have As stated in the introduction, the project approach targeted and increased the funds available for the to external assistance suffers from the weakness of respective sectors in almost all countries (Peters and insufficient sustainability. The recurrent cost impli- Chao: 183). Donors withheld aid in the Pakistan cations of all projects are not aggregated and fit into Social Action Program when government did not an overall framework of what is affordable. More- meet spending targets for social sectors (Peters and over, the project approach suffers from lack of im- Chao: 190). pact on increasing the overall level of allocations to One common problem in constructing an ap- the sector. The sector approach addresses these prob- propriate resource envelope is how to ensure that lems by defining a feasible overall resource envelope all sources of revenue and spending are covered, in- and targeting increases in the share of public re- cluding private sector contributions. A total picture sources going into the sector. Financial flows to any is frequently missing, owing to weaknesses in finan- one sector cannot be isolated from allocations to cial information and the channeling of donor re- other sectors. sources outside normal government accounts Determining the total resources available (i.e., (Jespersen: 9; Peters and Chao: 186-87). Another the "resource envelope") over the medium to long problem has been a weak link between the sectoral term is usually done through an overall public ex- approach and other reforms, such as civil service penditure review (PER) (Okidegbe: 7-8). The Ethio- reforms (Jespersen: 6). There is a risk in poor coun- pia health and education programs were both based tries in targeting a relative share of the budget. This on rigorous analysis of overall public allocations for may result in funds falling short of requirements. In 21 DESIGNING APPROPRIATE FINANCIAL PARAMETERS addition, earmarking shares of revenue for one sec- feedback was highly useful in setting and revising tor can lead to distortions. Sector approaches could priorities. distort overall patterns of public expenditure and Sector programs have to be explicit about re- threaten stability by increasing the level of funding source allocation priorities (Peters and Chao: 182). to particular sectors. Or, a rapid increase in funds to Just as development of the sector policy is an ongo- the sector could be followed by an equally rapid ing process, so too is elaboration of the financial decline at a later date (Cassels: 39). framework. Monitoring of actual expenditures must Defining a sustainable financial framework does be done periodically in relation to planned alloca- not mean shying away from supporting increases in tions. This is essential to ensure full funding of pri- public funding and budget deficits where they are orities and to limit the scope for fungability. justified by well-designed programs that address key Monitoring, in turn, requires complete, up-to-date policy issues over a longer term. Private financing and readily available (i.e., transparent) information should be emphasized. Developing a sustainable fi- about actual expenditures. In addition, procedures nancial framework involves setting priorities for both must be in place for the appraisal of capital projects public and private financing of the sector. to provide a sound basis for annual budget negotia- tions (Cassels: 40). Experiences thus far indicate that completely BUILDING A MEDIUM-TERM EXPENDITURE transparent information has been problematic. In PROGRAM FOR THE SECTOR Ethiopia the government officials announced plans to change intrasectoral budget priorities (increas- Once a feasible and appropriate aggregate level of ing allocations to higher education, which was con- allocations to the sector has been agreed on, the next sidered by donors to be of lower priority) just weeks step is to ensure correct allocations within the sec- after annual consultations with donors in which tor. The task is to make expenditures consistent with no allusion was made to the imminent changes. In sectoral strategies and priorities, and to ensure that several other cases, such as Ghana health and Zam- available sectoral resources are used as cost-effec- bia health, annual reviews were delayed or ham- tively as possible (Cassels: 39). The underlying as- pered by lack of timely information about actual sumption is that greater impact will be achieved by expenditures. (a) combining all donor and government resources Most disagreements in the preparation of in one program, and (b) focusing these integrated sectoral expenditure programs have concerned (1) resources on priority interventions. the relative balance between subsectors (tertiary As stated above for the policy framework, an health and education generally occupying a higher essential step in ensuring consistent allocations is place in the set of priorities of government than of for stakeholders to agree on the sector expenditure donors), and (2) the relative priority given to capi- program. This stakeholder participation has to be tal development vs. recurrent spending. In develop- structured to focus on priorities within overall ment of the Ethiopia health program substantial resource constraints. Levels of government that will discussion took place on this topic that eventually be included in implementation should be involved achieved a better balance between capital and recur- in stakeholder participation (Jones: 40). These rent spending, one that was more feasible in the long lessons were underscored in the development of the run. Similar discussions took place during the de- Ethiopia education program. Initial attempts at velopment of the Ghana health program. consultation with regional officials placed no Another issue in long-term financial planning financial limits on suggestions, which then pertains to uncertainties about donor contributions. ballooned to unrealistic proportions. A second Donor commitment cycles are often out of phase attempt set budgetary ceilings and the resulting with government budget cycles. Donors may not be 22 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA able to commit funding at the time it is needed by The level of financial analysis was weak in some government. Or, worse, they may commit funds, then of the cases reviewed. The Mozambique education not disburse. This happened for both the Ethiopia program deferred the analysis of education finance education and health programs. Several donors sus- until implementation. Zambia education deferred pended assistance in response to the start of the war the sector expenditure review, making it a condition with Eritrea. The Mozambique education program for phase II of the APL. It is difficult to see how addressed the problem of late donor commitments intersectoral allocations and overall spending pri- by financing a core program that can be expanded orities can be made in the absence of thorough public later as additional donors contribute. expenditure reviews. Despite the importance of a careful review of Finally, one case was observed of "best practice." investment programs and projects the sector-wide Development of The Gambia education program cases examined did not present much evidence of used a computer-based projection model to assess attention to government procedures for selection of the cost implications of alternative strategic choices investment subprojects. This contrasts with earlier based on core assumptions. This served two purposes: sector investment projects, which focused on ap- the model facilitated the selection of strategic alter- praisal and selection of subprojects by an interme- natives, and it also became the basis for monitoring diary. (See Thomas (1994) and Johanson (1985).) progress during implementation. 23 CHAPTER 6 DESIGNING IMPLEMENTATION SYSTEMS In 1998 Utz (13-15) found that sector-wide programs (2) management of sectoral services, and (3) pro- in the Africa region suffered from 65% disburse- gram management, including management of finan- ment lags and registered 43% as problem projects cial flows and procurement (Harrold: 22; Cassels: (compared with an average of just 24% for all 41). In Chapter 1 a "Catch-22" was noted, i.e., the projects in the region.) In part these delays reflect inherent tension between requiring good implemen- the complexity of sector programs. Sector programs tation capacity as a precondition for starting the de- inherently are more complex than traditional velopment of a sector program and using the sector projects, and being sector-wide, have to deal with program to develop this capacity. Clearly an assess- the problems of the entire sector. Sector-wide pro- ment of institutional capacity is needed to establish grams also tend to be launched in the context of whether minimum levels of capacity exist both to major institutional reforms such as restructuring of start the process of program development and to central ministries and devolution of authority to the decide whether implementation capacity warrants field. The difficulty of these reforms tends to be un- the committing of funds to the program. Several derestimated. Another reason explaining weak sources (Okidegbe: 17; Jones: 41) recommend start- implementation performance is weak institutional ing with an assessment of institutional capacity and capacity of the recipient country (Cassels: 41). Utz having an appropriate institutional framework in (10) concluded that not enough attention was paid place before embarking on implementation. Harrold to implementation issues in the preparation of sec- (26) refers to a sector institution assessment (SIA) tor-wide programs. as a critical means to form a judgment on govern- Requirements for implementation should be re- ment implementation. garded as high priority in the design of sector-wide Assessment of institutional capacity should con- approaches. The design of effective implementation centrate on the key issues of incentives, accountabil- systems involves four aspects: (a) analyzing existing ity, workload, and control of access to resources institutional capacity and planning for its strength- (Harrold: 26). The Tanzania integrated roads pro- ening, (b) developing performance monitoring sys- gram exemplifies why incentives are so important. tems, (c) financial management, and (d) procure- Ultimately the program faltered because of a lack of ment. Each of these topics is treated in sequence these incentives for key implementation personnel. below. Road engineers in Tanzania were not paid well enough to carry out their additional duties assidu- ously under the program, and local contractors could ANALYZING INSTITUTIONAL CAPACITY not be paid fast enough to keep them working. Analysis of institutional capacity should go be- Institutional capacity is complex and involves at least yond the limits of the sector organization. In par- three types of capacity: (1) leadership capacity, ticular, the analysis should consider the flow of funds. 25 DESIGNING IMPLEMENTATION SYSTEMS This is made more important by the frequent use of education, and Zambia health. The Gambia educa- sector programs to implement devolution of admin- tion case stands out in contrast as an excellent ex- istrative authority from centralized systems to re- ample of systematic institutional analysis, as shown gional and district authorities. Constraints on the in Box 6.1. flow of funds is a common reason for under- Unfortunately, this type of institutional analy- disbursement in sector programs. Funds were allo- sis is not cheap, in the order of approximately cated to regions in the Zambia health program, but $50,000. One clear conclusion from the review is that did not get passed on to the intended districts. Ini- institutional analysis is an essential prerequisite for tial disbursements have been slow under the Ethio- commitment of funds under a sector program. Avail- pia education program in part because of difficulties able tools for institutional analysis should be applied in getting funds from the center to the regions. Analy- more systematically. sis should also examine likely staff reactions to de- A well-designed Adaptable Program Loan (APL) centralization. In the Senegal health program can deal with institutional constraints. "Triggers" for resistance is being experienced to decentralization future phases, for example, could be specific improve- from several quarters. Institutional analysis could ments in structure, staffing, or procedures under the have pinpointed these likely points of resistance in first phase. advance so that compensatory measures could have been adopted. Staff working on several of the programs re- MONITORING PERFORMANCE viewed felt that there had been insufficient analysis of institutional capacity prior to commitment of Proper monitoring of performance against agree- funds. These include Zambia education, Ethiopia ments includes two things: (a) information systems institutional Analysis in The Gambia EducationiPoa An E l f Bt One of the unique characteristics ofthe Gmbeducation APL is the sy ticevuation thawas done of institutional capacity. This followed a m o aall the prped activities in the Program in terms of five criteria: whether (a)teuins andactties haean appropriate organizational home; (b) the level of leadersip ag t iesuffcet operating funds are available for the implementatn of assigned actie(d) the unithshright number of people with the right mix of skills-based on a worloadanais; and (e) kEy ties are efi cient and effective. This assessmet identifid sral ca igps. Fr exmet nlisfund that curriculum development and in-servie teacher inig hadimp* p' mamet responsibil- ity outside the Ministry of Education. Aoter e p in terms of wk prcticesw t weak - ordination among units in the Ministry.The next stepwternati fill the caiy gap through (i) changed practices and procre isen vities over a longer time- including the introduction of atw-phase appach andponemntfs tivties tothe sec- ond phase; (iii) reallocating financial and human resoue; rth s of th devel- opment objectives. In the end the Gamiaedcation APLinl a iled asiof all major institutional components involved int v programa ile y buildigmasres. Source:- Gambia education case study. 26 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA to collect, analyze, and report data on implementa- fundamental threat to the sustainability of the sec- tion; and (b) procedures for joint review of perfor- tor-wide approach. (Grindle: 5) mance. Each is presented in turn below. Experience from the implementation of Bank- funded sector programs shows that considerable time is indeed required to design and implement moni- Information Systems toring and evaluation schemes. The Zambia Agricul- ture SIP demonstrated this point. Virtually every Given the orientation of sector-wide improvements sector program has suffered in the first two years from to processes (e.g., tracking improvements over time), inadequate and late information needed to ascertain the quality and timeliness of data collection are of levels of performance. One practice to counter this paramount importance. Information on perfor- phenomenon and ensure the reliability of the infor- mance is doubly important in cases in which dis- mation is to use external agencies to collect or verify bursements are made against achievements, as is the data, as is being done under the Pakistan Social Ac- case in the Ghana health program. According to tion Program and the Ghana health program Cassels (43) and Peters and Chao (195) three types (Harrold: 38). Some projects muddy the waters by of data need to be collected: (a) monitoring of in- having too many indicators, so that priorities get lost dividual delivery centers and performance at vari- in the many types of data to be collected and reported. ous levels of the system against objectives, (b) Referringto health programs, Peters and Chao (185) aggregating performance for the sector as a whole found there were 9 national level indicators in against each objective, and (c) on processes such as. Senegal, 20 in Ghana, 23 in Mozambique, and 40 in policy development, institutional development, and Sierra Leone. The importance of indicators was un- management performance. The key attributes of derscored in the Zambia health program, which ran performance indicators are clarity, consistency, into difficulties when disagreements arose about the specificity, sensitivity, and ease of collection directions of policy change. Agreed, objectively veri- (Harrold: 38). Moreover, the number of indicators fiable, and explicit core indicators were missing. With- should be kept to a manageable number. Donors out these it was difficult to ascertain whether the should agree not to file any additional requests with government was in compliance, as shown in Box 6.2. the government for information, but live within Another particular issue about indicators arose agreed indicators. in the Ethiopia education program. Final targets were The development of information systems in- clearly specified, but they had not been broken into volves several issues. Ideally, indicators should es- interim steps for monitoring annual performance. tablish the extent to which growth of output can be Finally, indicators by themselves are not enough. As attributed to better policies, efficiency gains in the emphasized in the Ghana case, there must be a sys- administration of public expenditures, or improved tem to collect the information, analyze the results delivery of goods and services (Okidegbe: 6). In prac- and report them. tice, however, there are difficulties of measuring and especially attributing impact at the sectoral level (Grindle: 5). Moreover, establishment of systems for Joint Reviews assessing impact takes time and requirements are consistently underestimated. So far, the development Joint reviews between donors and government au- of data systems has received some attention, but re- thorities are the main instrument for assessing mains weak in the development of sector programs progress, resolving issues, and reaching agreements (Jones: 30, 37, 41). Weaknesses of monitoring and on the program. The joint reviews are at the heart evaluation have been identified by the Department of sector-wide processes. In most cases they take the for International Development (DFID) as the most place of, or largely replace, supervision missions by 27 DESIGNING IMPLEMENTATION SYSTEMS BOX 6.2 0X;: t:Lack of :: M onitring I:dictrs in te amia Hea1lth Proram ; In hindsight, four years after the start of proect implementation, itis clear that; the directions for development of the sector were not made fulloyexplicit. There were no objectively verifiable indicators that could define adherence or deviation from te agredpan. T much was left to interpretation and opinion. The Bank did not agree with the Government and other donor partners on outcome indicators, indicative targes, and hilestones for jo n ite prgpram. In retrospect, useful indicators would have been spending as a proportion of budgets on primary, secondary, and tertiary facilities; and availability of drugs. There should h been speific, clarly stated milestones, e.g., the Cenitral Board of Health (CBOH) estalishedl th an;acele memorandum of understanding between CBOH and the Ministry of Health; lgistion supporting decentralization passed, etc. It is therefore advisable first to get baseline data aand agreeon incators andnot to mae commitments until there is explicit agreement on what constitute progress. Source: Zambia health case study. donor agencies. Legal conditions are frequently tied regime (Peters and Chao: 186, 190). The critical is- to the processes, such as annual reporting, and fi- sue is not that difficulties will arise, but rather nancing of agreed annual plans (see Box 6.3, Senegal whether mechanisms and procedures are in place health). for dealing with them when they do (Cassels: 3). All These joint reviews normally take place twice a parties must be prepared for negotiations and com- year, in late spring and fall. The spring meeting con- promise in solving operational problems, character- cerns actual progress over the past year and achieve- istics that have not been typical of the larger donor ment of targets and objectives. The fall meeting deals agencies. Cassels wrote (56) that in handling disagree- with the establishment of targets and commitment ments it is helpful to classify potential problems ac- of funds for the coming year. These meetings, and cording to the following hierarchy: (a) agreements the information to be considered, need to be planned on sector strategies and exclusion of activities in- carefully in advance (Ghana health). According to consistent with sector programs, (b) degree of fit supervision reports on sector-wide programs (Ethio- between policies and spending plans, (c) common pia health and education); (Senegal health, and Zam- management agreements, and (d) performance not bia education) the effectiveness of the joint reviews up to expectations, e.g., funding shortfalls that should are often handicapped by weak government report- trigger formal consultation. ing on performance. In Zambia, the fall meetings More thought and planning needs to be devoted were generally more successful than the spring meet- to contingencies before commitment of funds (Jones: ings, partly because of the priority attached to com- 37). Because of the wide scope, sector programs are mitment of funds for the following year. more vulnerable to macroeconomic shocks than Joint meetings serve the indispensable function more narrow projects. Disruptions are probable. Staff of providing a venue for dealing with problems. A turnover is so critical and likely that one reviewer key question that those considering entering into said it could be "considered generic rather than in- sector programs should ask is: how will the partner- cidental" (Jespersen: 4). In the Zambia health pro- ship hold up over repeated conflicts and changes in gram major problems arose when a new Minister of 28 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA BOX 6.3 Modus Operandi for Senegal Health The Sectoral Investment Program emphasizes a continuing policy dialogue and phased funding, based on yearly operational plans, eligibility criteria for program resources, and sector-wide perfor- mance indicators. This is achieved through joint Government/Donors annual implementation re- views. The joint annual reviews are the key element in the implementation process. The program is being implemented through a series of joint annual agreements based on an assessment of previous years' performance and operational plans and budgets based on priorities and established eligibility criteria for access to program funding. This procedure allows Government, IDA, and other financ- ing institutions to adjust to changing conditions and performance, thereby building in a higher level of flexibility that will allow for more realistic planning on a year-by-year basis. Plans call for five such annual agreements, each covering one fiscal year from 1998 to 2002. Each will summarize the detailed individual agreement for specific categories of expenditure. Annual reviews are timed to coincide with the Government's fiscal year. Monitoring and information systems, common for all donors, are a key to the success of annual reviews. Two sets of data are collected: (a) critical perfor- mance benchmarks-for the first two years these include placement of program management staff, acceptable allocations to each expenditure category, levels of disbursement, recruitment and train- ing of staff and Management Information Systems (MIS) in place in all districts; and (b) perfor- mance indicators for districts include: increases in the use of health facilities, proportion of children vaccinated, increases in pre-natal consultations and increases in contraceptive prevalence. Source: Senegal health case study. Health took over with a markedly different set of sector, top to bottom, wall to wall. Examples of this policies and priorities. Planning for contingencies were personnel strikes in Senegal and Ghana. These such as these should be an integral part of good pro- activities could be ignored under a project, but must gram preparation. be addressed under a sector program. Implementa- tion requires continued sector analysis and updat- ing of the policy framework. Extensive preparations Providing Adequate Resources for are required for semiannual joint review missions. Monitoring Implementation All these things imply the need for appropriate and sufficient staff and budget during implementation. Sector programs have clear resource implications that The resources can come from several sources, includ- may not be fully appreciated by Bank management. ing funds induded in the loans/credits, e.g., for field These programs are much more complex than stan- audits, studies, and evaluations. Much of the bur- dard operations. The attempts to work through gov- den will also fall on the Bank's supervision budget, ernment procedures, the need to harmonize with but these budgets for sector programs have tended other donors, the wide scope of activities covered, not to be proportional to the wider scope of activi- and the reforms introduced (e.g., decentralization) ties involved in a sector-wide program. They tend to all add layers of complexity to the operation. Do- be underbudgeted in terms of the size and complexity nors have to be concerned about all policies in the of the operations. The consequence is less intensive 29 DESIGNING IMPLEMENTATION SYSTEMS coverage of subprograms. Realistic estimates should A precondition for the use of government fi- be made in advance of resource requirements and nancial systems, of course, is donor confidence in the various sources should be identified. the financing system and a track record of proven capabilities (Jones: 27). The first step toward use of government procedures is strengthening the struc- FINANCIAL MANAGEMENT ture of the public budget to monitor spending bet- ter (Peters and Chao: 184). This is not a simple Budgeting and Expenditures process and may take years or even decades to achieve. One of the reasons that Ghana has gone Another distinguishing characteristic of sector-wide the furthest in pooling donor funds (discussed be- programs is the use of regular government struc- low) is the confidence that donors have in the fi- tures, systems, and procedures. The overall objec- nancial management system. This confidence, in tive is to strengthen government systems by using turn, is the product of decades of sustained work and improving them. None is more important than on its improvement. the system for budgeting and expenditures. Since Donors can frustrate budgetary reform by (a) achievement of sectoral objectives depends on ef- disbursing money without regard to the national fective use of government resources, sector programs budget, or (b) failing actually to provide the funds must be tied to regular procedures for budgeting and when agreed (EU: 11-12). planning. The intention is ultimately to disburse One exemplary practice identified in this re- funds through normal government channels rather view is the financial incentives for good implemen- than using special-purpose accounts and separate tation performance built into the Ghana health channels. Better management of public expenditures program. Disbursements are contingent on the level and systems is a critical requirement if there is to be of performance. Disbursements are set at $7 mil- progress toward government ownership and bud- lion per year, but can be adjusted up or down by getary support (Jespersen: 6). 50% based on actual performance by the Ghanaian Varying 1Dlsusi"t c.dn oPefx.c n aahat An IDA Credit forU$5mlinpnieb aeaon o S7mlinprya.A neetn feature of the Crediti h osblt ovr nuldsusmnsi eaint efrac.Cn ditions for baseline fnigicue()teovrmnmetitficlom tensofnancing the Program of Work PW,ad()adt ftePWdmntaeaeut iclpoiy SR 18). If these conditiosaentmtthBakwuddcesIAamutbeotebsli.Fex ibility also exists to nraeteaonsdsusdhsdo he diinlcniin:()cpct to implement the PO asmarebyaiiyt pdacodntoOWpns()annrasg gap between the budgti adaalbegatfns nwihcs D ud ol eue ofl h gap; and (c) strongshwnonteareseofscopeoraciniaosInheuueits expected that financnwllbeplctylnetoproaneoagedscoiniaos(A:1) Consistent with this flxblt,Shdl fteCei greetlae S3 ilo f$5ml lion, or 86%/, unallocatd Source: Ghana ~healt caestd 30 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA BOX 6.5 Zambia Health: The Start of Pooling Donor Funding The Zambia program pioneered the use of "basket funding," or pooling of donor contributions into a common account. The idea of financing against the government budget started with the proposed DANIDA grant funds to districts. Although this idea did not materialize during the design stage, do- nors supported the concept during implementation. Donor funds were pooled for district grants and made use of common accounting and reporting procedures developed with DANIDA assistance. Separate donor accounts were established at the center. Funds were released monthly and were com- mingled at the district level, i.e., donor origins could not be identified. The release of funds by the center was negotiated with all donors. Each donor had veto power. Source: Zambia health case study. authorities in meeting program targets, as explained tended, transparency, and accountability. Many do- in Box 6.4. nors are reluctant or unable to pool their funds with other donors. Some of the reasons apply to the do- nors themselves. Some donors simply do not have Pooling of Donor Funds instruments for financing recurrent costs or provid- ing direct budget support. Others find it difficult to The ultimate objective is "basket funding', or pool- adjust their financing procedures and timetables. ing of donor resources with government funds-in Some do not want to lose the identity of their funds effect, pure budgetary support. These funds would as a donor (i.e., attribution, or "raising the flag"). then be dispersed, used, and accounted for through Other reasons apply to the recipient government. The normal government channels. Under pooling of budget process may be deficient, allowing diversion donor resources different funds from different do- of funds from high to low priority items. Rivalries nors would no longer be identified separately, and may block disbursement of funds to intended ben- would no longer be earmarked for different purposes. eficiaries. It may not be possible to ensure full ac- Payments would be made into and out of a com- counting of funds and the risks of wastage may be mon account rather than via reimbursement of spe- unacceptably high (EU: 7; Peters and Chao: 185; cific expenditures (Cassels: 46). There are two steps Jespersen: 10). toward this ultimate goal: (1) pooling of donor funds; There are only a few examples of pooling of and (2) commingling of pooled donor funds with funds in sector-wide projects in the Bank. These government funds. include the Zambia technical assistance and health The potential benefits of pooled donor funds are district funds (see Box 6.5), common disbursements enhanced government ownership of the program, under the Bangladesh health sector program; dis- incentives for better budget planning, less likelihood trict funds under the Senegal health program; and of budgetary imbalances, strengthening rather than preparation studies for the Zambia education pro- bypassing government procedures, rapid disburse- gram. The best example of pooling of funds is the ments, lower costs to manage donor funds, and greater Ghana health sector program, as described in Box opportunities for budgetary reforms (EU: 6). 6.6. The requirements for pooling on the recipient In the Ghana Health program, the Bank accepted side are assurances that funds will be used as in- that it would not be able to trace the specific expen- 31 DESIGNING IMPLEMENTATION SYSTEMS A unique feature of the IDA Credit is the use of acmon account and pooling of resources. The Ministry Of Health has gone a ln w t tbish fiancial management sytems that will ensire appropriateuse and accounting offs.Themajorityof donr fundslining the IDA Credit, will be nanaged on llnes0 ofxtinggoenment 6proedures.Some earmarked project funds will continue over the medium term, but teprerred donrficin ytem is an untied contribution into a common Heath Acount. OnAce ID andothertdon f rea fcthe Heath Account, there is no further identification of the by dororigin, thustfare gnuinely pooled. MI A is putting all its contributions tothe program into the pool. Three other donors are putting part of their contributions into tfiepool e rest of the resources andthse of other donors are earmarked funds, but are not provided in thetaditionlm e asteyarepanne din to the annual planning and budgeting cycle, and Care channeled through the Financial Controller in an accountable manner, rather than directlyto p m sin iation ther funding. 'The Health Account funds are put into al bank accountfunder the direct control of MOH and the Controller and Accoun- tant General. These funds, are then distributed to all egle health units that meet minimum "Readi- ness Criteria", including: (1) submission of annual budget accompanied b quantified targets and objectives; (2) satisfactory procedures and collecinand acunting fridpendently generated funds; (3) adequate procedures for authorization of payments; (4) adeqateand timely maintenance of accounts; and (5); ade staf and procedures to prepre monthly reports on revenues Xand expenditures. Source: Ghania health case study. diture of Bank funds. Instead, it relies on annual As is pointed out in the Senegal health case, pooling audits of government expenditures, including pooled of resources need not be the first step, but is the ul- government, donor, and IDA funds. timate objective. There can be stages toward achiev- Examples of pooling are clearly in the minority. ing full budgetary support (Jespersen: 10). Instead of pooling, most sector-wide programs thus far earmark funds (i.e., typing of donor funds to a specific activity output.) For example, parallel financ- Lender of Last Resort ing channels were specifically identified in the Zam- bia education program and these alternative channels Considerable confusion surrounds this topic. It helped greatly to clarify the choices for donors. (See means the Bank, since it loans money, will finance Box 6.7). Even Basket funding in Ghana, Zambia what cannot be financed through grant funds (be- health, and Senegal health operate in parallel with cause generally it is better for a government to re- project accounts for individual donors (Grindle: 5). ceive grant money than loans'). It means the Bank 'Still, it should be remembered that the grant element in IDA loans is almost 80% because of the low interest rate in relation to inflation. 32 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA will finance the residual left after grant funds have Application of the donor of last resort concept been allocated. However, it does not mean that low means different things depending on how program priority items should be financed. Jones ( 11) has funds are managed. If funds are earmarked, then the pointed out the risk that the donor of last resort will donor of last resort finances those items of the pro- end up financing items of lower priority or those gram that are left after other grant donors select the that are less fashionable. However, being lender of components they wish to finance. When funds are last resort does not really mean financing lower pri- pooled, all components and items are financed out ority items, because the expenditure program will of a common account. Under these circumstances have been thoroughly vetted to ensure that only im- the lender of last resort finances the gap between portant items are funded. In practice, it probably available (grant) funds and total resource require- means the Bank will end up financing more civil ments. works because other donors generally do not want In practice, being lender of last resort requires to use their grant funds for building. Financing of the Bank to maintain flexibility to adjust the objects civil works is not a problem if the budget has been and amounts of its disbursements from year to year. properly screened and low priority components have Specifically, Bank sector programs need to keep large been removed. It really does not matter who finances unallocated amounts in the schedule of disburse- what, so long as the full program - limited to the ments. This is clearly seen in the Ethiopia education highest priority activities - gets funded. As Harrold program that has about two thirds of the total funds (35) pointed out, "Under the sector-wide approach unallocated. the Bank's project is the sector, not the actual goods A donor of last resort is also needed for a sector and services it happens to finance." program because promised donor funds often do not BOX 6.7 Multiple Channels for Donor Funding in Zambia Education The Preparatory Fund for the Basic Education Sector Program received funds into a common ac- count ("pooling") by several donors, induding the United Kingdom, The Netherlands, Ireland and Norway. This became the model that Government wished to use for the full program implementa- tion. "Pooling" was recognized as the ideal method during the joint appraisal, but was not foreseen as being acceptable to most donors because of weaknesses in existing capacity for financial manage- ment. Instead, the Program was explicitly designed to allow flexibility in the channeling of funds by donors. The following external financing modalities are recognized: Source, Zambia education case study. Category Case 1 Case 2 Case 3 Case 4 Funds controlled by: MOE MOE MOE Donor Funds available for which Program components: All All Limited One or a number small number 'Pooling" of funds in common account Yes No No No Examples of donors using each method Dutch, Irish IDA 33 DESIGNING IMPLEMENTATION SYSTEMS BOX ~6.8 mFinnng of lhe ESSP in Mo biqu˘c The financing plan for the program was drafted during the joint donor assessment mission in May 1998 and further refined during appraisal in late 1998. By appraisal a total of about US$85 million had been comrnitted to ESSP by various donors to support ongoing activities that were part of the program. Approximately US$105 million in additional fuinds were expected to be provided by donors over the five-year program period. The schedule for agreement on n;ew funds would follow the pro- gram cycles of the various agencies. The normal approval cycles for the various donors meant that commitment of new funding would be drawn out over two or three years. A number of donors also (e.g., Denmark, the Netherlands, Sweden, Ireland, and the United Kingdom/DfID) planned to pro- vide about US$70 million of their funding for the program through direct budgetary support. Bud- get support was entirely new. No one knew exactly how to do it. Soome donors complicated the funding picture further by Vmaking their new f unding contingent on the provision of budgetary sup- port by at least a core group of donors. Conseqny there was considerable uncertainty over when (and perhaps whether) new funding would materialize from several key donors. The Bank therefore shifted from its intended role as donor of last resort to the immediate financing of several core com- ponents. Financing of the core program by the Bank was designed to ensure continued financing of the program as a whole pending the release of other donor funding. Source.: Mozanmbique education case study. materialize when needed. The Mozambique educa- choose components they wish to finance, with the tion program financed a core program to which other Bank picking up the remainder-should be accepted donor funds could be added when ready, as explained only as a step toward the broader strategy of pool- in Box 6.8. ing and channeling funds through the budget. In practice, the Bank as lender of last resort has had mixed success. In the Ethiopia education pro- gram it helped allay suspicions by other donors that PROCUREMENT the Bank was trying to dominate, but complications arose when other donors delayed in providing funds. Goods and Works: The harmonization of financial In Zambia health, the Bank's special account ended procedures seems almost simple by comparison to up being used as a slush fund to finance anything the difficulties in harmonizing different donor re- not provided elsewhere. This underscores the im- quirements on procurement. This is because the portance of agreement in advance on an exclusive procurement rules of donors are often not designed expenditure program. for a sectoral approach (Jespersen: 10), but rather The important thing, in the final analysis, is that to stimulate the purchase of goods and services from (a) program formulation and expenditure reviews the donor country. "Rules of origin" are thus a ma- have eliminated unjustifiable expenditures, and (b) jor obstacle, but waivers are reportedly possible in there is explicit agreement in advance of what is ex- some cases (Cassels: 47). On the government side, cluded from the expenditure program. Moreover, the authority for procurement and capital projects the "patchwork" approach-where donors pick and can be so complicated as to stall the entire system. 34 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA There is a risk under harmonization that the Min- that external technical assistance should (a) not be istry is forced to adopt the procedures of the most used in line positions; (b) be provided only in re- restrictive donor (Cassels: 47). In most cases pro- sponse to government requests; and (c) be used to curement is divided and follows the rules of the complement, not supplant, local expertise (Harrold: source of funds (Peters and Chao: 184), a practice 17; Jones: 27; Okidegbe: 9). If too much technical that is viewed as sub-optimal by many. One prob- assistance is requested, this is symptomatic of deeper lem mentioned was the lack of early involvement problems, such as disagreements on strategy or a poor of financial and procurement specialists at the de- institutional environment (Jones: 28). It may also sign stage of sector programs. Another problem was stem from unrealistic expectations for the sector a discrepancy between a standard procurement program and a tendency to encourage state-of-the- schedule in the Credit Agreement of the Ghana art where this is unrealistic (Jespersen: 11). health program and the intentions expressed in the Finally, the staffing implications of sectoral pro- project appraisal document (PAD) for common pro- grams need to be considered carefully. This means: curement procedures. (See the Ghana health case.) (a) frequent interaction between government offi- Technical Assistance: More success has been cials and donor staff who can speak authoritatively achieved in establishing common funds for techni- on behalf of donors - which may require staffing of cal assistance. Examples include Zambia health and local offices (Cassels: 58-59); (b) changing or up- education; Pakistan SAP, Bangladesh health, and grading of donor staff capacity to deal continuously Zambia agriculture SIP (Okidegbe: 9). On another with policy analysis and issues; and (c) adequate bud- topic, Harrold stressed the value of minimizing ex- geting for supervision that tends to be 50-100% ternal technical assistance and even included it as (Zambia 50%, Mozambique education 100%) the sixth major characteristic of SIPs. In practice greater than normal projects. Larger-than-normal many donors have insisted on the use of external budgets are fully justified by the scope of activities technical assistance, especially in financial manage- and subprograms, sometimes equivalent to several ment and procurement. There is general agreement projects. 35 CHAPTER 7 MAIN FINDINGS AND RECOMMENDATIONS Sector programs are inherently complex. Complex- Complexity comes at a price, in terms of more ity is derived from: (a) the broad scope, the concern time and resources required for development and with everything in the sector-top to bottom, wall supervision of sector programs than traditional to wall-(b) donor coordination-never an easy task, projects (in the order of 50%-100% more) and more but made even more complicated by the extremely time required for program development and imple- high number of donors involved in many of the Af- mentation. The staffing implications are: (a) differ- rican countries, (c) the attempts to channel external ent mix of skills than for projects, with an emphasis resources through the government budget, and (d) on policy analysis and ability to negotiate with high the simultaneous efforts at major sectoral reforms, level officials on policy matters; (b) the need for a such as decentralization. All these factors add layers local technical presence to keep the dialogue going of complexity to sector programs. Complexity is not and coordinate with other donors; and (c) possibly a weakness per se. It only becomes a weakness when more frequent missions to keep abreast of sector de- ambition exceeds capacity. velopments. BOX 7.1 Changes of Personnel and Policy Derail the Zamba HeaJth Program During program development and implementation there have been four different ministers of health. The second minister tried to sidetrack the reforms, but Parliamentarians supported the health manifesto and brought him back into line. Broad approval was required to delink the health staff from the civil service (including defeating lawsuits) create the Central Board of Health, and turn dis- tricts into autonomous boards. Thus, the reform had broad-based and high-level support. Prior ex- periences with changes of leadership had not altered the directions of reform. All that changed in 1998 when a new minister of health was appointecL The new minister changed priorities and placed emphasis on support for tertiary care institutions and centralization. This reversed some reform strategies. The new minister took an adversarial relationship with donors. The openness that had prevailed evaporated. The minister prevented an open dialogue in the 1998 annual meeting. Imple- mentation of the program came to a standstilL DANIDA suspended most of its program. Few funds have been disbursed from the IDA Credit in over one year. Several procurement applications have been rejected by the Bank. Source: Zambia health case study. 37 MAIN FINDINGS AND RECOMMENDATIONS It is still too early to tell whether sector-wide succeeded in increasing the relative shares (and ab- approaches in the social sector are making an im- solute amounts) of public resources going into the pact, but some of the successes and weaknesses to respective sectors. date can be identified, as follows: WEAKNESSES SUCCESSES OF THE SECTOR-WIDE APPROACH Design of Sector Programs Sector-wide approaches address many of the prob- lems and issues that contribute to poor performance Some of the sector programs reviewed did not by projects. They have strengthened the ability of include rigorous sector analysis. Since policy the government to oversee the sector, develop poli- analysis is an ongoing process, staff felt that any cies and allocate resources. (Peters and Chao: 188). gaps could be made up during implementation. They have led to the development of comprehen- However, this risks an inappropriate or misguided sive plans and strategies. In all the eight cases re- policy package. viewed the government developed a long term The main weakness identified in the prepara- vision and strategy for the sector. The dialogues tion of sector-wide programs was the lack of sys- conducted during program preparation have had tematic analysis of implementation capacity. Staff success in eliminating imbalances between capital felt that more could have been done to analyze and and recurrent spending. Sector programs have also fix implementation weaknesses. The tendency for been successful in achieving decentralized plan- overly ambitious sector programs in relation to ex- ning in several cases (e.g., Zambia health-bot- isting capacities has been noted, a corollary of their tom-up planning of district grants; Ethiopia complexity. Institutional analysis can be an antidote education and health both achieved district plans to overly ambitious tendencies. and strengthened district planning capacities). Sec- The review underscores the importance of tor programs have forged strong links between monitoring indicators. Several problems occurred. policy development, allocation of funds, and per- Explicit indicators were lacking by which to formance monitoring (Peters and Chao: 184). As determine and demonstrate deviation from policy concluded in the Ghana health case study, "For the agreements (Zambia health). In another case, first time health policies are being explicitly linked Ethiopia education, targets were not broken into to resource allocation in a comprehensive man- annual indicators for assessing the rate of progress. ner, covering all government and donor financ- Other programs have tended to include too many ing." Stakeholder consultation and participation indicators. has been strengthened (Jones: 14-15). All the eight cases were built on stakeholder consultation. Frame- works for donor coordination have been estab- Implementation of Sector Programs lished. Some common procedures have been achieved, particularly on joint appraisal systems, Problems and difficulties were the norm rather than annual reviews, and common reporting systems. the exception during implementation. The prob- Initial steps have been made in a few projects to lems can be categorized into three types: (a) Changes move to budget support by pooling external re- in the macroeconomic environment. The war be- sources and channeling them through the govern- tween Ethiopia and Eritrea is just such a change in ment budget. These measures have reduced the the environment that caused financing agreements administrative burden of external assistance on re- with other donors to unravel. (b) Changes in policy cipient governments. Finally, sector programs have directions. Ethiopia education may have changes 38 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA in policy direction, as indicated by changes in bud- A. Meet the Preconditions for Starting get priorities for higher education. Zambia health experienced major changes of policy that led to a (1) Ensure that the prerequisites are met for de facto suspension of the program, as described entering into the development of a sector- in Box 7.1. (c) Changes in key personnel. The people wide approach. Do not undertake a sector- who champion the sector program often are re- wide approach unless the client has (i) a placed by others less familiar with, and less com- modicum of stability, (ii) strong commit- mitted to, the sector program. In the Zambia health ment to an integrated, collaborative process, and The Gambia education cases these personnel and (iii) at least a minimum level of insti- changes led to at least temporary delays in imple- tutional capacity. In addition, ensure that mentation. the donor agency allocates adequate re- Problems and changes are inevitable. This fact sources and the right profile of staff for de- suggests the need for sensitivity and risk analysis as veloping a sector program. a basis for careful contingency planning. Yet, this does not appear to have been done in the cases reviewed. Bank staff may not appreciate the special risks in- B. Establish a Collaborative Process volved in dealing with ambitious sector programs. None has apparently undertaken contingency plan- (1) Do not rush the process of policy devel- ning in advance. One contingency for which the opment. Sector approaches are a long haul, Zambian health program was unprepared was the not a quick fix. Time must be allowed for complete breakdown in dialogue and de facto sus- reaching agreements on policy issues and pension of the program. The Bank had no remedies interventions, appropriate procedures, to apply except the extreme measures of formal sus- legislation and clear delineation of respon- pension and cancellation of the program. sibilities to ensure sustainability (Jespersen: Problems were also experienced in setting up 12). data collection systems for the key indicators. Al- (2) Recognize that success ultimately depends most all cases note weaknesses in management on the level of trust among partners. Trust, information and reporting systems (examples: Ethio- in turn, is based on openness, transparency, pia education and health; Senegal health; Zambia negotiation, and compromise. Appropriate education). mechanisms must be in place by which all All sector programs expect a great deal from the parties can raise and address problems and joint review process, perhaps too much. Virtually all their concerns. cases expressed disappointment with joint reviews. (3) Spell out the rights and responsibilities of The capacity required for government to organize all parties on paper at the start in a State- meaningful annual reviews has been underestimated. ment of Intent, and later in a Memorandum This includes (a) information retrieval on process, of Understanding (or Credit Agreement) product, and impact, (b) conducting ongoing stud- and Code of Practice. ies and analyses on specific issues, and (c) planning (4) Follow Government's lead, but ensure that detailed budgets. the ownership and participation is increased progressively from a narrow group of re- formers and includes participation of cen- RECOMMENDATIONS FOR BEST PRACTICE tral ministries and legislatures. (5) Harmonize procedures that are feasible Based on the findings of the review the following immediately, such as reporting, joint points are recommended as best practice. reviews, and monitoring systems. Also start 39 MAIN FINDINGS AND RECOMMENDATIONS with immediate steps to strengthen and process for reaching consensus through fur- improve government systems. Get central ther study and dialogue. Use an adaptable agencies to work on generic systems for all program loan (APL) with "triggers" set for sectors, such as finance and procurement, achieving consensus on difficult areas of rather than repeating the work sector by policy. sector. (6) Define the role of a donor lead agency in advance to avoid misunderstandings. Pro- D. Develop Financial Parameters vide sufficient administrative funds to pay for the high costs of coordination. (1) If it is not possible to invest in the sector as (7) Establish a joint technical assistance fund a whole, nonetheless monitor expenditures for project preparation to start the pooling sector-wide to ensure reasonable intra- of resources on a small scale. sectoral allocations. (2) Conduct public expenditure reviews before commitment of funds to establish an over- C. Establish a Comprehensive all resource envelope for the sector. Do not Policy Framework defer this to the implementation phase. (3) Use budget ceilings to force better selection (1) Start with a comprehensive policy frame- of priorities, as when regions prepare work covering the sector as a whole even if sectoral programs. subsequent investment programs have to be (4) Devote attention to the establishment of limited to particular subsectors because of sound government criteria and procedures capacity limitations. for appraisal and selection of specific invest- (2) Help build stronger analytical underpin- ment projects. nings for sector-wide programs by improv- (5) Meticulously plan the flow of funds from ing the quality and rigor of sector analysis the center to regions and districts to avoid during initial program design. the typical delays in disbursements. (3) Recognize that policy analysis is an impor- (6) Where other donor funding is uncertain es- tant ongoing function during program ex- tablish a core program of donor assistance ecution and focus attention (i) on building with Bank financing, and add to the core as local capacity for continuing policy analy- additional financing materializes. sis during implementation, and (ii) on (7) Use computer models for expenditure pro- buildingbetterinformationsystemsfordata jections during preparation and use the collection. same models during implementation for (4) Continue the good work shown on stake- monitoring performance. holder consultation. Widen the consulta- (8) Spell out the role of the lender of last re- tions beyond the bureaucracy to include sort. In particular, agree in advance on what front-line service workers and beneficiaries. specifically is excluded from the expendi- Use a clearly defined resource envelope to ture plan. ensure realism and facilitate hard choices (9) Accept "patchwork" arrangements-where among competing priorities. donors earmark funds for particular com- (5) Have explicit policy agreement on basic ponents-only as a step toward the optimal principles and priorities before loan ap- strategy, which is the pooling and channel- proval, an explicit list of policies on which ing of donor funds through normal govern- consensus has not yet been reached, and a ment budgets. 40 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA E. Build Management Systems and Capacity levels in the approval process, e.g., cabinets, and (iv) root the programs in legislation. (1) Use existing techniques more systematically Devise and install remedies at the design and rigorously for institutional analysis to stage in case things do not work out and identify and address weaknesses and con- the program deviates markedly from the straints before embarking on a sector pro- plan. gram. Go beyond organizational analysis to (7) After tapping other sources for financing consider staff incentives, identify who stands studies and reviews, be prepared to finance to gain and lose from program implemen- substantially larger than normal budget co- tation and plan in detail the flow of funds efficients for the supervision of sector pro- to beneficiaries. Since institutional analysis grams, recognizing that ongoing analytical is costly, budget the requirements separately work is costly to review and the scope of and fully in project preparation. Consider sector-wide programs encompasses the using an APL to overcome structural con- equivalent of multiple projects. straints for later phases. (2) Focus early and sharply on the development The net effect of the above recommendations is of monitoring and evaluation systems. Limit to expand the list of things that must be done be- the number of indicators to priorities and fore loan or credit approval, making the prepara- ensure that they indicate clearly whether the tion process even more demanding for a development program is on track annually. program than a traditional project. In summary, the (3) Design joint review procedures in advance following steps should be considered as essential and ensure that workable mechanisms are prerequisitesfor commitment offunding (i. e., in place in place to identify, address, and resolve by time of Board presentation) for sector-wide op- problems. Build government capacity to erations: manage joint reviews. (a) Policyframework developed, based on rigor- (4) Involve financial and procurement special- ous sector analysis, including specific three- ists early in the design phase to help in de- year work program (Ethiopia education). veloping appropriate systems. (b) Wide consultations with stakeholders and (5) Linkdisbursementsto achievements to pro- donors have been held, and agreement vide incentives for good performance. reached on priorities. (6) Engage in better risk analysis and contin- (c) Public expenditure review or social sector ex- gency planning for various types of occur- penditure review completed; overallfinan- rences. Think through systematically what cial parameters defined in terms of targeted would happen if critical changes happened intersectoral allocations and a budget enve- in the macro-environment, e.g., (a) if mac- lope for the sector, and agreement on bud- roeconomic shocks reduced sectoral allo- getpriorities for the first two years (Ethiopia cations below planned targets; (b) if health). disagreements arose on the policy frame- (d) Institutional capacity analysis completed and work; and (c) if key staff changed. Devise a agreement reached on early implementation set of courses of action for each contin- of a program to fill identified gaps. gency. For example, assuming that key per- (e) Monitoring indicators identified that show sonnel inevitably will change, (i) broaden clearly whether program implementation is the participation of stakeholders, (ii) pro- on track; data collection system designed and vide continuous training and briefings for in place on processes, system delivery and new personnel involved, (iii) involve higher impact (Ghana health). 41 MAIN FINDINGS AND RECOMMENDATIONS (f) The modus operandi designed for joint re- ance with, or substantial deviations from, views and problem resolution, i.e., mecha- agreements. nisms for common reporting, joint annual (i) Provision of the correct profile of staff and reviews of progress, budget planning, dis- adequate resources (including outside financ- cussion differences). ing and internal budgets) for program su- (g) The role of donor of last resort clearly spelled pervision. out (and specifically what is excluded from the agreed expenditure program), and a The following are other desirable but not essen- staged plan to achieve pooling of resources tial conditions for commitment of funds: among donors. 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Oxford University Press. 1999. New York. 43 BIBLIOGRAPHY Watkins, Kevin. 1999. "Education Now: Break the Million to the Republic of The Gambia for a Cycle of Poverty." Oxfam International, U.K. Third Education Sector Project in the Support of the First Phase of the Third Education Sector Program," Human Development I1, Country Africa Department 14, Report No. 17903-GM, August 7, 1998. Rakotomanana, Michel, et al. 1998. "Sector-Wide Approaches (SWAPs) and Donor Coordination in Educational Development in Africa: Perspec- Guinea tives for Enhancing Japan's Participation." Japan International Cooperation Agency, USA Office. World Bank. 1990. "Report and Recommendation May 30. of the President of the International Develop- Verspoor, Adriaan. 1999. "Knowledge and Finance ment Association to the Executive Directors on for Education in Africa." Draft, World Bank, a Proposed Credit of SDR 15.4 Million to the September. Republic of Guinea for an Education Sector Adjustment Credit." Report No. P-5288-GUI, May 11, 1990. Ethiopia World Bank. 1995. "Implementation Completion Report: Republic of Guinea, Education Sector Martin, John, and Riitta Oksanen, and Tuomas Adjustment Credit (Credit 2155-GUI)," Popu- Takala. 1999. "Preparation of the Education Sec- lation and Human Resources Division, Western tor Development Programme in Ethiopia: Re- Africa Department, Africa Region, Report No. flections by Participants." Cambridge Education 14617, June 16, 1995. Consultants, UK and FTP International, Finland. World Bank. 1995. "Staff Appraisal Report, Repub- Final Report, 7 June 1999. lic of Guinea: Equity and School Improvement World Bank. 1998. "Program Appraisal Document Project." Population and Human Resources Op- on a Proposed International Development As- erations Division, Western Africa Department, sociation Credit in the Amount of US$100 Mil- Report No. 13472-GUI, April 7, 1995. lion Equivalent to the Federal Democratic Republic of Ethiopia for the Education Sector Development Program." Human Development Lesotho IV and Country Department 6, Africa Region, Report No. 17739-ET, May 4, 1998. World Bank. 1999. "Project Appraisal Document on World Bank. 1999. "Quality at Entry Assessment: a Proposed Credit in the Amount of SDR 15 Guidance Questionnaire" as part of the Quality Million to the Kingdom of Lesotho for a Sec- At Entry Report for CY 1998, on the Ethiopia ond Education Sector Development Project in Education Sector Development Program. (Com- Support of the First Phase of the Education Sec- municated by Dora Aku Adoteye to Prem Garg, tor Program." Human Development 1, Coun- EM 10/8/99.) try Department 1, Africa Region, Report No. 18388-LSO, March 25, 1999. The Gambia Mozambique World Bank. 1998. "Project Appraisal Document on a Proposed Credit in the Amount of SDR 15.0 Republica de Mocambique. 1998. "Education Sec- 44 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA tor Strategic Plan: 1997-2001: Reviving Schools Health Sector Development Program Support and Expanding Opportunities." Ministry of Edu- Project. Credit Number 3140 ET. October 30. cation, Maputo, April 1998. World Bank. 1998. "Program Appraisal Document World Bank. 1999. "Project Appraisal Document on on a Proposed Credit in the Amount of SDR a Proposed Credit in the Amount of 51.1 Mil- 75.1 million (US$ 100 Million Equivalent) to the lion SDR (US$ 71 Million Equivalent) to the Federal Democratic Republic of Ethiopia for a Republic of Mozambique for an Education Sec- Health Sector Development Program." Report tor Strategic Program (ESSP)." Human Devel- No. 18366-ET. September 24. opment 1, Country Department 2, Africa Region, Report No. 1868 1-MOZ, January 22, 1999. Ghana Zambia Annan, Joe. 1999. "Ghana Health Sector-wide Programme: A Case Study." JSA Consultants, Chilangwa, Barbara Y. 1999. "Issues, Experiences, Ltd., Accra. Prepared for DAC I/CD Network and Challenges and Lessons in the Process of Estab- Policy Branch of CIDA, April 1999. lishing the Zambian Basic Education Sub-Sec- Decaillet, Francois. 1999. "Ghana: Health Sector tor Investment Programme (BESSIP)." Paper Support Project-Back to Office Report." June prepared for the annual meeting of the DAC's 1, 1999. Institutional and Capacity Development Net- Peters, David, and Shiyan Chao. 1998. "The Sector- work, Ottawa, Canada, May 3-5, 1999. Wide Approach in Health: What Is It? Where Is World Bank. 1999. "Program Appraisal Document It Leading?"InternationalJournal ofHealth Plan- on a Proposed Credit in the Amount of SDR 28.5 ning and Management 13: 177-190. Million to the Republic of Zambia in Support of Republic of Ghana. 1998. "Memorandum of Under- the First Phase of the Basic Education Subsector standing: Ghana Health Sector Programme of Investment Program (BESSIP)." Human Devel- Work." April 30. opment 1,CountryDepartment 2,Africa Region, Republic of Ghana. 1999. "Health Sector 5-Year Report No. 19008 ZA, March 5, 1999. Programme of Work 1997-2001: 1998 Review." Ministry of Health, Accra, April. World Bank. 1997. "Memorandum and Recommen- THE HEALTH SECTOR dation of the President of the International De- velopment Association to the Executive Directors Cassels, Andrew. 1997. "A Guide to Sector-Wide on a Proposed Credit in the Amount Equivalent Approaches for Health Development: Concepts, to SDR 25.1 Million to the Republic of Ghana Issues and Working Arrangements." WHO, for a Health Sector Program Support Project." DANIDA, DFID and EU. Report No. P 7179 GH, September 25, 1997. European Union. 1999. "Sector-Wide Approaches World Bank. 1997. "Staff Appraisal Report: Repub- (SWAPs) as a Means to Develop Sustainable lic of Ghana Health Sector Support Program." Health Services and Policies." Health Experts Human Development III, Ghana Country De- Meeting, January 1999. partment, Report No. 16467-GH, September 25, 1997. "Aide Memoire: Joint Ministry of Health-Health Ethiopia Partners Summit Meeting (May 5-7,1999), Re- view of the 1998 Programme of Work." 7 May World Bank. 1998. Development Credit Agreement: 1999. 45 BIBLIOGRAPHY Senegal Approach to Lending?" Presentation at HNP Training Day for HD Resident Mission Staff. 19 World Bank. 1997. "Staff Appraisal Report: Republic March. of Senegal, Integrated Health Sector Develop- . 1998. "Supervision Report: Zambia Health ment Program." Report No. 16756-SE. August 8. Mission" April 2. Republic of Zambia Ministry of Health. 1998. "Memorandum of Understanding Between the Zambia Ministry of Health and Cooperating Partners in the Health Sector." July. Joint Donor and Ministryof Health Statements. 1994, World Bank. No date. "Turning the Tables for 1995, 1996, 1997. Zambia's Health System." Handout in the "In- Mahler, Halfdan, et al. 1997. "Comprehensive Re- vesting in People" and "The World Bank in Ac- view of the Zambian Health Reforms." Report tion." Human Development Department. of an independent review in September 1996. World Bank. 1994. "Staff Appraisal Report, Zambia: May 1997. Health Sector Support Project." Human Re- McLaughlin, Julie. 1997. "What Can We Learn from sources Division, Southern Africa Department, Implementation of a Sector-Wide Investment Report No. 13480-ZA. October 14, 1999. 46 ANNEX 1 List of World Bank Staff Interviewed 1. Arvil Van Adams (Ethiopia education) 10. Bruce Jones (Zambia education) 2. Anwar Bach-Baouab (Senegal health) 11. Julie McLaughlin (Zambia health) 3. Rosemary Bellew (The Gambia education) 12. Paud Murphy (Zambia education) 4. David Berk (Ethiopia health) 13. Eliezer Orbach (The Gambia education) 5. Nicholas Burnett 14. Ok Pannenborg 6. Francois Decaillet (Ghana health) 15. Robert Prouty (Guinea education Secal) 7. Linda Dove 16. Jee-Peng Tan 8. Birger Fredriksen 17. Adriaan Verspoor 9. Donald Hamilton (Mozambique education) 18. Steve Weissman 47 ANNEX 2 Ethiopia Health Case Study' Health Sector Development Program Support Project BACKGROUND THE PROGRAM: OBJECTIVES AND STRATEGY Ethiopia's burden of disease is dominated by acute In response to these issues the Council of Ministers respiratory infection and peri-natal and maternal adopted a National Health Policy in September 1993. conditions, followed by malaria, nutritional The Policy calls for decentralization of health ser- deficiency, diarrhea, and AIDS. The top 10 causes vices; development of preventive and promotional of mortality account for 74 percent of all deaths components of health care; assuring accessibility of and 81 percent of discounted life years (DLYs) lost health care for all segments of the population; mo- prematurely. The main issues in the health sector bilization of and maximal utilization of internal and are: (1) low and inequitable coverage of basic health external resources for development of the sector- services (only about 45 percent of the population including cost recovery on the basis of ability and has access to a health facility); (2) low quality of promotion of private and non-government organi- services because of lack of drugs, poorly trained zations in health care. staff, and poor personnel management and The National Health Policy was further devel- supervision; (3) inefficiency in the use of resources oped and refined-in part with Bank assistance in terms of concentration of available resources in through a PHRD grant-and presented as a Health urban areas and skewed allocations toward curative Sector Development Program (HSDP) at the Con- care. Historically the health sector has been sultative Group Meeting of Donors in Addis Ababa underfinanced and resources are misallocated in December 1996. This 20-year program seeks to across diseases. The ten diseases that cause 76 develop a health system that provides comprehen- percent of DLYs lost in Ethiopia consume total sive and integrated primary case services for all Ethio- spending of only 45 percent of recurrent pians, primarilybased at communityhealth facilities. expenditures. The Government health care system The focus is on communicable diseases, common has been highly centralized and reliant on vertical nutritional disorders, environmental health and hy- programs. giene, reproductive health care, immunization, the I Based on the Project Appraisal Document for a Health Sector Development Program, September 24, 1998, Report No. 18366-ET and interview with former Team Leader, Mr. David Berk. 49 ANNEX 2: ETHIOPIA HEALTH CASE STUDY TABLE 1 Life expectancy Overall 52 5 5-60 Males 49.7 56.2 Females 52.4 59.2 Infant mortality rate (per 1,000 live births) 110-128 90-95 50 Maternal mortality rate (per 100,000 live births) 500-700 450-500 300 Health Services Expand primary health care coverage (% of population) 45 55-60 90 Immunization (DPT3) coverage 67 70-80 90 Contraceptive prevalence 8 15-20 40 treatment and control of basic infectious diseases, ity of health personnel, (4) improvements in the epidemic diseases, and sexually transmitted diseases. pharmaceutical sector, (5) information, education, The 20-year program (1997-2016) starts with and communication, (6) health sector management a first phase of five years (July 1997-June 2002). An and management information systems, (7) moni- IDA-financed Health Sector Development Project toring and evaluation and applied research, and (8) provides the equivalent of US$100 million to sup- improvements in the financial sustainability of the port the first phase. Key indicators of progress in health sector through greater efficiency and mobili- health status and services for the first phase and zation of additional resources. full 20-year implementation are set out in the table below: The Government strategy to achieve these tar- SWAP DESIGN gets includes: decentralization of operational respon- sibilities through a four-tier system (primary health Bank Lending Instrument: Specific Investment Loan care units, district hospitals, regional hospitals, and (SIL) specialized hospitals) based on defined minimum Rationalefor the SWAP: A sector-wide approach standards, greater public funding for health care, was adopted to support the overall program. The expansion of facilities into underserved areas, an climate of opinion in the Bank favored adoption of emphasis on preventive care and community-based the sector-wide approach and the Government's ini- delivery of health services; and increased supply and tiative in preparing an overall sector policy suggested logistics systems for essential drugs along with bet- the need for a SWAP. ter quality assurance and better training for front- SWAP characteristics: The operation has at least line and middle level health service providers. five elements that have been identified with SWAPS, Accordingly, the first five-year phase of the HSDP namely: (1) an overall policy framework, (2) an ex- includes the following components: (1) expansion penditure framework, (3) agreement by the main of primary health care access through provision of donors to the program, (4) the government had facilities according to predefined physical norms, (2) enough influence over the process to call it owner- improvements in the technical quality of service ship, and (5) attempts at common implementation provision, (3) expanding the supply and productiv- arrangements. 50 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA Preconditions: Ethiopia met several basic precon- shop in March 1997 (together with the Education ditions for starting the development of a sector-wide Sector Development Program), (4) Three multi- approach: It had achieved macroeconomic stability. donor missions (October 1997; February 1998; May Through previous investments it had demonstrated 1998) which in effect were identification, prepara- at least a minimum level of institutional capacity for tion, and appraisal, but different terms were used. program execution. Above all, it had demonstrated The Government produced a detailed Program Ac- commitment to a sector-wide process through the tion Plan (PAP) for appraisal. Another key docu- definition of first its National Health Policy in 1993 ment, the Implementation Manual, was finalized by and then the development of the HSDP by 1996. the Government after Board presentation. Donors Definition of the sector: A pragmatic decision was were incorporated into the process relatively late in taken on the definition of the health sector for op- the game, by which time many basic parameters for erational purposes, namely: whatever the Ministry the program had already been decided. The main of Health (MOH) dealt with. Thus, the sector is com- substantive issue during the dialogue with donors prehensive rather than limited to certain subsectors, was the composition of the capital and recurrent yet does not get into practical difficulties of cross- budgets. At the urging of the donors the Govern- ministerial responsibilities. The "sector" is congru- ment saw that the original capital-heavy program ent with the existing management units for planning could not be sustained. Changes were made to and budgeting. achieve a better balance between capital and recur- Program leadership: By default leadership for the rent expenditures. development of the sector program was vested on Level of sector analysis: Development of the pro- the government side in the Office of the Prime Min- gram benefited from several analyses. Two PHRD ister (PMO). The Ministry of Health had lost sub- grants financed thirteen studies that provided in- stantial managerial capacity through a government- put into the definition and refinement of the HSDP. wide process of decentralization. Key staff either were However, the Government did not wait for the re- moved to the regions or left the Ministry rather than sults of these studies before writing up its program. be reassigned to regions. This left a capacity and lead- It is not clear whether the studies were ever drawn ership vacuum in the MOH. The Minister in charge upon fully. In addition, the Bank undertook a Pub- of social sectors in the PMO was the former Minis- lic Expenditure Review in 1997 and a Social Sector ter of Health and was fully conversant with sectoral Review in 1998 that provided a basis, inter alia, for issues and requirements. On the side of the donors, its economic analysis of the program. in theory the donor group was the counterpart to Instruments for agreements: The Government the government. However, the Government asked prepared the documents (policies, plans and manu- the Bank to take the lead in the preparation of the als) that set out objectives, means, and obligations. program and lead the missions. Consultation be- Donors agreed to provide support based on these tween donors and Government was achieved through documents. A specific Letter of Sector Policy was joint participation in the Sector Steering Commit- written and addressed to the Bank. Late in the pro- tee, which induded the Ministry of Finance and was cess the idea was discussed of having a Memoran- chaired by the Minister in the PMO. dum of Understanding setting out responsibilities Program development: Program development among the various participants. Government resisted included the following main stages: (1) formation the idea, saying they did not see the need given all of a Task Force to prepare a National Health Policy the other documentation produced. that was adopted in September 1993; (2) prepara- Institutional capacity: No special instruments tion of the HSDP, in part with Bank assistance, by were used to assess institutional capacity at the cen- December 1996; (3) presentation of the HSDP by ter or in the regions. The central MOH had been the Government to the donor community at a work- gutted by the departure or defection of key person- 51 ANNEX 2: ETHIOPIA HEALTH CASE STUDY nel during the process of decentralization. The MOH procedures for most procurement, with thresholds had no confidence in its ability to perform its new set relatively high. Attempts have been made to de- role of technical support to (without supervisory velop standard bidding documents and processes in control over) regions. Donors established a condi- a way that would be acceptable for use by other do- tion for further processing of assistance that sector nors. It is expected that some of the donors will agree management be strengthened and improved. This on common thresholds for procurement methods was accomplished. Particular attention was devoted and reporting formats at the post-review level, thus during appraisal to institutional capacity for pro- reducing MOH's administrative burden. Donors may curement and financial management, including spe- also agree on the use of standard documents and cialists in these fields in the missions. procedures for advertising, evaluating, and award- Stakeholder consultation: Ethiopia has had an ing contracts. autocratic tradition. Authorities felt they"knew best" Disbursements: Funds are not pooled under the what should be done. Consistent with this, authori- Program. HSDP financial management uses the ex- ties were not much concerned with consultation with isting channels: The Ministry of Finance passes funds stakeholders and beneficiaries. There was a belated from both central government and donors (kept attempt to contact NGOs, but overall little was done. separately) to the central MOH and to regional of- Donors did not challenge this approach. One con- fices of the MOF, where regional offices of the MOH sequence is a risk that the proposed approach to im- will obtain their share of total regional funds. A single proved medical care at the local level may not be set of accounts in agreed format show all sources accepted, and expected increased utilization of ser- and uses of funds for HSDP at each level. Thus, IDA vices may not materialize. will make disbursements against eligible expendi- Financing: IDA is providing US$100 million and tures based on statements of expenditure (SOEs) or other donors about $215 million for a five-year pro- full documentation for payments above SOE thresh- gram that is expected to cost about $750 million. olds. IDA will advance funds into a central govern- The Government, thus, will finance about 55% of ment Special Account for IDA's share of program total costs. The Bank is playing the role of the "lender expenditures. Project accounts have also been opened of last resort," i.e., financing components left after in each of the regions to cover IDA's share of the other donors have chosen what to finance. This role annual work program and budget. is complicated because some donors-mainly for Risks and dangers as a SWAP: The magnitude of reasons of Ethiopia's war with Eritrea-have slowed the sector program means that it is more vulnerable or suspended their commitment of funds. It has also to macro shocks than would be a smaller project (for meant by default that the Bank will finance a high which some funds could normally be found to fi- proportion of the civil works component. This was nance its continuation.) If this happens, it would considered acceptable since the civil works is part mean doing less, i.e., scaling down tertiary health of a well-defined overall expenditure framework di- facility targets, or slowing down capital expenditures rected at high-priority objectives. Also, civil works so as to reduce associated recurrent expenditures. is not the only component that the Bank will finance. Another risk is that donors may not provide resources Schedule 1 of the Credit Agreement leaves 65% of as intended. This risk appears to have been realized the credit proceeds in the unallocated category to because several donors have slowed contributions promote flexibility in allocations. This allows funds in response to the war. Another issue concerns imple- to be shifted quickly from activities that are not do- mentation capacity. Since the Ministry of Health has ing well to others that are, or to activities of greatest to do or supervise all procurement, rather than need at the time. multiple PIUs as would be the case under separate Procurement: The Credit Agreement required donor projects, its implementation capacity is national competitive bidding according to national strained. Another complication of the SWAP ap- 52 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA proach is getting financial flows the way everyone Modus operandi and instruments used: Targets wants them. exist for the various subprograms, but it is not known Conditionality: Conditions of effectiveness in- in advance what specific components will be fi- clude preparation of the Project Implementation nanced, where, and when. These specific funding Manual, and adoption of an acceptable plan to decisions are to be made during the course of imple- strengthen financial management. It took an ex- mentation based on annual programs and budgets, ceptionally long time to declare the credit, largely overall and by region. Key to this is the joint Gov- because of the difficulty in reaching an acceptable ernment donor annual review. The annual review financial management plan. Conditions of disburse- examines actual achievements and performance ment on subprograms include (1) (a) prior IDA under the program of the previous year and decides approval of the subprogram, and (b) preparation on the budget and targets for the next year. Annual of an operational plan for the subprogram (includ- reviews allow the work program to be adjusted ac- ing reforms, activities, financing required, sources cording to past performance and changing circum- of financing, and a procurement plan), and (2) sat- stances. In turn, a key requirement for the annual isfactory evidence that (a) the budget for the sub- review is development of the management infor- program is consistent with overall Program mation system of the MOH. Semiannual Implemen- objectives, and (b) previous expenditureswere made tation Progress Reports are being submitted by in compliance with Program objectives. In effect, implementing agencies covering: (1) expenditure implementation of the annually agreed program is data from the previous six months; (2) data on physi- a condition for commitments from year to year. The cal targets achieved (and actual achievements as a financing levels are highly flexible. If the Govern- percentage of targets); (3) procurement status re- ment reduces its level of financing of the Program port and plan for the next two years; (4) issues and (as appears to be now emerging), IDA reduces its problems; (5) action plan to resolve the problems. financing. Poor results from one year can lead to Reports by regions and the center are then integrated reduced new financing for the next year. No other into a consolidated report for consideration by the special remedies are incorporated into the legal Central Steering Committee (CSC). The Annual agreement. Review Package, in addition, includes information on monitorable indicators, review of priorities and strategies, reports on special studies and updated SWAP IMPLEMENTATION work programs and proposed budgets. Efforts have also been made to harmonize donor procedures. Do- Organizational arrangements: The HSDP is imple- nors have agreed to work together to harmonize the mented by the central Ministry of Health and Re- financial accounting and management systems. The gional Bureaus of Health (about 90% of the long term goal is to have all donors use Govern- expenditures are below the central level). Coordi- ment channels for the flow of program funds and nation is provided by a Central Joint Steering Com- reporting. mittee (CJSC) and Regional Joint Steering Implementation experience: The Program has Committees. The CJSC is chaired by the Senior Min- been under implementation since 1997, before the ister for Social and Administrative Affairs in the PMO. IDA Credit of $100 million was approved. One an- Other members include the Ministers of Finance, nual review has been held since IDA Credit approval. Economic Development and Cooperation, Health, The initial annual review turned out to be less than Education and three donor representatives (currently satisfactory. The implementing agencies produced the Bank, UNDP, and USAID.) The Planning and generally weak progress reports. After much discus- Projects Department of the MOH serves as secre- sion about indicators and reporting systems, the tariat to the CJSC. management information system is not yet installed 53 ANNEX 2: ETHIOPIA HEALTH CASE STUDY even after two years of Program implementation. gram was able to learn from the experiences of the Another problem detected is the poor organization education program, which was developed on a sched- and procedures to follow up on new government ule about six months ahead of health. The health commitments. Another problem has been the reluc- program used the same cycle of mission, for example. tance of some donors to meet their commitments- As a result, the health program started work on because of the war, particularly those donors who implementation aspects earlier than education. The previously had been for more general budget sup- health program also addressed the issue of manage- port. There have been few disagreements among ment capacity in the MOH early, during the prepa- donors and government on policy matters-mainly ration process. Finally, in general, the process of because the worldwide consensus that exists in the donor coordination and involvement through the health sector on strategic priorities and means of Steering Committee and annual reviews has proved intervention. to be workable. OUTCOMES SO FAR LESSONS Main achievements: (1) Rebalancing sector expen- The following lessons should be noted: ditures, i.e., reducing the excessive capital expendi- tures to achieve a more proper balance with recurrent (1) Donors should become involved earlier in expenditures and increase the likelihood of finan- the process of program development, be- cial sustainability. (2) The Government now under- fore Government has made up its mind on stands more fully what goes into a sector program. key aspects. In particular, the regions have undergone an exten- (2) Proper stakeholder consultations should sive learning process in terms of preparing regional take place, and stakeholders should have a plans. (3) The MOH has a stronger setup for imple- greater role in the steering groups. mentation. (4) The Government has learned how to (3) Get donors to commit to move together with deal with donors and their foibles. The health pro- financing. 54 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA TABLE 2 756 - ETHIOPIA, HEALTH SECTOR Project Status Report Date: 6/24/99 Region: APR Country: ETHIOPIA Sector. HB Lending Instr: SIL Prg Obi Cat; PA EA Cat: B PTIt Y NGO? N Resettlment? N LOAN INFORMATION Agree L/C/G Orig Re'd currency Prod Signing Effective Suppi Puj Type No Amt Amt Indicator Line Date Date ID IDA 31400 75.10 (SDR) PE 10/30/98 3/11/99 Total Original Amount (SDR): 75.10 Total Revised Amount (SDR): 0.00 COFINANCING INFORMATION Agency Board Amount ($M) Current Amount ($M) Total 0.00 0.00 Guarantee Type: Guarantee Amount ($M): This form is part of: Portfolio status update Read together with: Aide-memoire Mission End Date: This Form PSR Date: 6/24/99 BTO memo of: Months since last mission: Last Form PSR Date: 1/22/99 Follow-up letter of: Next mission planned: SUPERVISION EFFORT Total Total Field Field As of Staff-Weeks $000 Staff-weeks $000 6/2499 Current FY - Planned 21.80 85.92 Current FY - Actual 29.85 93.52 0.00 0.00 Board through preceding FY 0.00 0.00 0.00 0.00 Total Actual 29.85 93.52 0.00 0.00 UPI No. Mission Member Division No. of Fld Days Role or Specialization PrevMiss 55 ANNEX 3 Ghana Health Case Study' Health Sector Support Program ACRONYMS fertility rate is 5.5, about 8 percent of children un- der 5 years suffer from severe malnutrition, and large BMC Budget and Management Center disparities exist between regions, particularly in the (functionally and administratively north. According to the 1998 Ghana Demographic accountable units) and Health survey, infant mortality is 56 per 1000 GHS Ghanaian Health Service (with neonatal and post-neonatal deaths respec- HSSP Health Sector Support Program tively at 29 and 27 per 1000). Under-five mortality MOH Ministry of Health is 107 per 1000 births, having significantly decreased MOU Memorandum of Understanding (30% in the last 15 years). Fertility has declined dra- MTHS Medium-Term Health Strategy toward matically over the last decade from over 6 births Vision 2020 (The Policy Framework) per woman in the mid-1980s to 4.5 births per POW Five-Year Program of Work, 1997- woman during the last five years. At current fertil- 2001 (The Operational Framework) ity rates, women in rural areas will have nearly twice SAR Staff Appraisal Report as many children (5.4) as women in urban areas (3.0). About 40 percent of the population still does not have access to health facilities and 50% do not BACKGROUND have access to safe water. Utilization of curative ser- vices is quite low, with only 0.39 annual visits per Health and population outcomes and service pro- capita in public facilities. Quality is constrained by vision indicators are slightly better in Ghana than shortages of supplies, absence of services, question- the average for Sub-Saharan Africa with mortality able staff behavior and absence of quality assur- trends improving at a faster pace. Since indepen- ance programs and beneficiary feedback. In the dence in the early 1960s life expectancy has increased mid-1990s Government expenditures on health from 45 to 55 years. Ghana has one of the more declined, particularly for non-wage recurrent ex- advanced health systems in Africa, including a rela- penditures. Rather than targeting the poor, Gov- tively strong district health management system. Yet ernment resources have been disproportionately the health status of Ghanaians is still poor: the in- spent on less cost-effective tertiary levels of cura- fant mortality rate is about 66 per 1000, the total tive care. (President's Report: 2.) 'Based on interviews with Mr. Francois Decaillet. detailed comments by David Peters and the documents cited at the end of the case study. 57 ANNEX 3: GHANA HEALTH CASE STUDY A health reform program was articulated in a gram versus a project approach is to improve Medium-Term Health Strategy: toward Vision 2020 sustainability (p.2 1). Under the sector approach all (MTHS). The four sector policy guidelines for re- financial requirements and funding sources are con- source allocation are to (a) make more resources sidered in one envelope. The capital investment pro- available for attainment of universal access to pri- gram is scrutinized carefully, including implications mary health services and shift the emphasis increas- on recurrent expenditures. Agreement on levels of ingly to the primary level; (b) increase the share of financing and monitoring actual performance non-wage items in the total recurrent budget; (c) against those targets help to ensure that the pro- achieve a better balance between development and gram will be financially sustainable. Institutional recurrent budgets; and (d) realign existing inequali- sustainability will be enhanced by focusing on im- ties in regional allocations. proved management practices and support to regular The Bank had two previous credits dealing solely institutions and processes rather than separate or in part with health. About 15 donors and techni- project structures and donor-based processes. In ad- cal agencies had been active in providing assistance dition, the comprehensive sector approach, founded to the health sector, contributing just under 30% of on a basic package of services designed to balance public expenditures on health. One of the major cost-effectiveness and equity, was seen as a means problems prior to the MTHS was the lack of an over- to achieve greater impact in solving chronic prob- all framework for integrating the many donor- lems in the sector. The Bank wanted to support the assisted projects. Investment decisions were made Ghanaian-led initiative on health reforms. It pro- in isolation, there were many vertical programs and vided a forum to consider openly a full range of parallel management systems, and a lack of congru- public policy and allocation issues, and adopt com- ence of project aims. These tended to fragment rather mon goals and strategies. In contrast, traditional than build capacity. Coordination of activities of projects diverted implementation capacity and du- donors and technical agencies, as well as multiple plicated efforts, lowering the chances for reporting requirements, was becoming increasingly sustainability and coordinating financing with sec- unmanageable and disruptive to Government. tor priorities (SAR, p. 8). Context The HSSP benefited from a history that was conducive for a sector-wide approach. First, the SWAP DESIGN Government had achieved substantial macroeco- nomic stability in the 1980s through its economic Lending instrument: The project is classified as a Sec- recovery program. Despite setbacks in the early 1990s, tor Investment Loan (SIL) and was used informally growth was strong in the mid 1990s, including a 5.2 as a test case for an Adaptable Program Loan (APL). percent increase in GDP in 1996 and a reduction in The project is clearly a Sector Investment Program inflation from 71 percent at the end of 1995 to 29 because it meets the following criteria: (1) sector- percent by June 1997. Second, the Government had wide in scope; (2) based on an overall policy and demonstrated considerable institutional capacity expenditure framework; (3) Government leadership through its earlier reforms in the health sector, in- and ownership of the program; (4) donors financed cluding the establishment of district health services, a share of the investment program and agreed to development of financial management systems, and harmonize procedures; (5) use of government in- successful implementation of numerous externally stitutions and procedures for implementation of the financed assistance programs. In short, an adminis- program; and (6) minimal use of long- term exter- trative and institutional basis existed on which to nal technical assistance. build. Third, the Government had led the process of Rationale for the SWAP: According to the SAR, defining a long-term policy and strategy for health one of the reasons for selection of the sector pro- sector reform and, by definition, claimed strong 58 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA ownership for them.2 Despite the progress it had Program leadership: The Government itself de- achieved, problems in health care were still massive, cided to adopt a sector-wide approach to overcome suggesting the need for a new approach with greater fragmentation of projects, which results in a heavier impact. burden on the Government. Donor agencies assisted Definition of the sector: The definition of the sec- in the development of the strategies and programs tor for the health program is comprehensive. It cov- but the Government was very much in the driver's ers all activities in the health sector. This ranges from seat for the entire process. The leadership tended to individual and household health decisions to formal be exercised by a relatively small number of senior service delivery, advocacy, institutional arrangements, officials in the central MOH.3 Leadership emanated and policy addressing public and private providers from the Minister of Health who initiated the pro- and other stakeholders and beneficiaries of the health cess, but was soon taken over by a group including sector. The financing of the program cover all Gov- the Director General, the Director of Policy, Plan- ernment and donor-assisted activities, both recur- ning, Monitoring and Evaluation, and a few key Di- rent and developmental, so that all input can be rectors (External Aid, Human Resources, Health directed toward common objectives (SAR, p. 9). In Research Unit). However, the emphasis was on giv- terms of other sector plans, such as nutrition and ing more authority and responsibility to Regional population control, the Plan of Work (POW) speci- Directors and District Medical Officers, creating lo- fies what operational responsibilities would be in- cal changes and power bases. duded. For example, the health services elements of Donor coordination: A forum for donors and nutrition strategies (e.g., prevention and control of some NGOs was in existence for decades in Ghana, micronutrient deficiency) are included. Food secu- but had not succeeded in overcoming the perceived rity initiatives are not part of the health sector POW. constraints on coordination. Donors stuck to their Communications, essential obstetric services and systems and procedures and insisted on being iden- management of sexually transmitted diseases are part tified with particular projects. From the Government of the health interventions included in the POW perspective separate donor projects afforded indi- (SAR, p. 10). Essentially the POW covers all activi- viduals the opportunity to command and control tiescontrolledbytheMinistryofHealthandtheGha- selected programs and benefits, e.g., study tours naian Health Service. (In addition, several ministries abroad. However, small groups of donors in the were involved in approval, consultation, and divi- MOH responded to the ever more pressing need for sion of labor. Finance, Planning, Control and Accoun- coordination brought on by the multiple demands tant General, Auditor General, and Head of Civil imposed by projects and the need for a more coher- Service were needed for "approval" on different as- ent sector plan to achieve vital development objec- pects of the program. Consultation was needed from tives (Annan: 5). At present monthly meetings are many Ministries (e.g., education, etc.), and a divi- held for the Government-donor coalition. Better co- sion of labor was needed with Ministries of Local ordination was achieved by a number of steps: chang- Government and Environment). ing the chairmanship of the coordination group over 2 This occurred more during the course of preparation than as a precondition to undertaking the approach. Project staff stated that one should avoid too much reference to preconditions. When starting dialogue about SWAPs one is setting out development objectives instead of prerequisites. 'One reviewer noted, a close relationship existed between a small group of health sector donors and a core of senior MOH personnel. From 1996 onwards technical assistance was provided to introduce the sector-wide program. "The principal effects of donor funding on local ownership of strategies were the acquiescence to specific donor preferences" (Annan, p. ii). 59 ANNEX 3: GHANA HEALTH CASE STUDY to Government; conducting joint missions, prepar- pital care and be balanced better with recurrent ing joint TOR, dividing up the work, and frequent financing. In terms of modalities the most diffi- formal and informal consultations. In addition, in- cult areas for agreement were on financial man- formal consultations were frank, open exchanges, agement and procurement procedures, especially which have persisted to this day. The main factor the pooling of donor funds. was the openness of the Ghanaians to discussing any Level of sector analysis: There was considerable issue. sector analysis already done-on health status, on Program development: The MTHS was devel- health determinants, on NGOs, beneficiary assess- oped after a National Consultative Meeting on ments, etc. Bank staff added a procurement assess- Health Development in late 1993. This was followed ment, an assessment of financial management by 14 working groups to further develop feasible (and specific review of each BMC for clearance), strategies. A Steering Committee then consolidated an institutional assessment, and a public health the wide variety of inputs into the MTHS. "Do- assessment. nors and technical agencies, led by the World Bank, Instruments for agreements: The Government's agreed in principle that supporting a common Sec- plans and programs provided the basic instruments tor Investment Program based on the Government's for agreements, particularly the POW and annual health sector strategy was the way of the future. ... work programs. Late in the design stage, after ap- To this end, the health donors agreed to support proval of the IDA Credit, a Memorandum of Un- the MOH in evolving a five-year Program of Work derstanding was signed by other donors along with from the Strategy. Paradoxically, to reach this turn- a Code of Practice. These documents were used to ing point where partners were 'on board" it had specify the roles and responsibilities of the Govern- taken nearly three years of fragmented project type ment and donors during implementation. Other key arrangements to support the sector-wide approach" instruments used included joint aide memoires (with (Annan: 8). After the painful process of getting out other donors and government), joint mission TORs, the MTHS, the POW was basically formed by fol- and agreement on a single set of monitoring reports. lowing the discipline of the new budgeting and Institutional capacity: Institutional assessment planning cycle. A new budget and plan were re- was done in 1994, and supplemented by other as- quired, so that efforts were first made to get each sessments of specific parts of the institution and its BMC to produce its plan and budget, and then to beneficiaries as was needed. pull them together at the national level. It is diffi- Stakeholder consultation: According to the cult in retrospect to identify any clear-cut stages President's Report considerable consultations took for IDA in getting to negotiations and Board ap- place in the design and initial implementation of the proval. There were consultations and meetings, and HSSP. Both the Consultative Meeting and the work- considerable back and forth on the agreements ing groups had broad representation of stakehold- reached. These included numerous meetings be- ers in public and private sectors in Ghana. Outside tween Legal, Disbursement, Bank Procurement ad- the MOH, active partnership is being sought with visors, and the AFPH4 team. At one point the missions, other NGOs and private practitioners, sup- project staff met with some concerned Executive pliers of goods and services, universities, and research Directors over the procurement issues. The project institutions. There have also been increasing efforts was also taken to the Regional Operations Com- to involve health consumers in health reform dis- mittee, and the main Operations Committee, to cussions. Studies on user satisfaction indicate a move- formally review the project before negotiations and ment within MOH to assess client expectations. the Board. The main disagreements on policy dur- Efforts are being made to make the reform as broad- ing program design concerned the capital budget, based and populist as possible (pp. 8, 10). Another which needed to be reduced to focus less on hos- review, however, states that non-health and non-state 60 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA actors were poorly represented in the planning and efficiency of primary health services by establishing implementation of the sector-wide program, and standards of practice for a priority package of ser- there was little "grassroots" input. "As a result of the vices, retraining health workers, rehabilitating clin- limited stakeholder participation, the priorities and ics, health centers and district hospitals, providing local needs identified, which require a broad con- essential drugs, equipment and supplies according sensus, lack full legitimacy" (Annan: 9). "Though to standardized lists, and strengthening management leadership was provided, it was not apparent that and administrative systems in the decentralized sys- the sector-wide process through its top-down ap- tem; (2) strengthening and reorienting secondary and proach had increased professional ownership beyond tertiary service delivery to support primary care; (3) a small group" (Annan: 27). "The MOH recognized training adequate numbers of new health teams, in- the need to build consensus around its strategy, but cluding in-service training, expanded and restruc- this proved elusive largely due to the donor-induced tured pre-service training, rehabilitation of schools, haste to develop a more fundable Program of Work" provision of supplies and teaching materials, revi- (Annan: ii). sion of curricula and retraining tutors; (4) improv- ing the capacity of the MOH for policy development and analysis, resource allocation and performance THE PROGRAM monitoring and regulation of service delivery; (5) strengthening national support systems for person- Objectives and content: The HSSP seeks to implement nel management, supplies management, and finan- the MTHS, as defined more specifically in the five- cial management and health information; (6) year Program of Work (POW). The ultimate aim is promoting private sector involvement in health ser- to improve the health status of Ghanaians. The two vice delivery, including development of contractual main goals of the reform program are to: (a) pro- arrangements, regulatory, and licensing mechanisms; vide universal access to a basic package of health and (7) strengthening intersectoral collaboration in services and improve the quality and efficiency of terms of advocacy for nutritional and population health services; and (b) foster linkages with other programs. sectors to reduce population growth rates, reduce Organizationfor implementation: The long-term the level of malnutrition, etc. Program impact tar- vision is to use common implementation arrange- gets are as follows: ments for the public sector, regardless of the source The POW presents seven strategies with con- of the funding. This entails developing and strength- tent as follows: (1) improving the access, quality, and ening existing systems rather than building TABLE 1 Indicator Basdine Target 2001 Life expectancy (years) 58 60 Infant mortality (deaths per 1,000 live births) 66 50 Under-five mortality (per 1,000 live births) 132 100 Maternal mortality (per 100,000 live births 214 100 Annual population growth (percent) 2.75 Total fertility rate (births) 5.5 5.0 Children with severe malnutrition (percent) 12 8 Source: Staff Appraisal Report, p. 9. 61 ANNEX 3: GHANA HEALTH CASE STUDY separate systems for each project. The program, project-specific funds through the Financial Con- therefore, is being implemented through the regu- troller rather than directly to program managers; lar channels of the Government. No new project prohibition of independent monitoring visits by implementation units have been established. The cooperating partners; and MOH responsibility for MOH is responsible for policy, monitoring, coordi- planning annual reviews. nation of donors, and public financing for health All planning and budgeting are now being done services. As a transition toward single Government on the same schedule and not separately for each systems over time, in the medium term the program donor-funded activity. Government and donors is being managed by tightly coordinated parallel and jointly review the detailed action and financing plans common implementation arrangements for those at a national level on an annual basis. Two annual with existing projects. The Ghana Health Service and meetings are held by the MOH with donors and tech- two Teaching Hospital Boards are managing the de- nical agencies. The first, in about April is called the livery of public health services in a decentralized con- "Health Summit" and concerns an annual assessment text. They prepare and implement health budgets of performance and audit of the previous year. An and monitor health performance. Responsibility and extensive joint review is conducted by the Govern- authority for service delivery are delegated to vari- ment and representatives of donor agencies prior to ous BMCs, including 110 district health management the Health Summit. The outcome of the Summit is teams that are responsible for organizing and pro- a set of priorities and budget ceilings for the next viding local health services. Ten regional health teams year. The second meeting, in September, is limited play an intermediary role between the district teams to agencies providing flexible Program Financing, and the central GHS (SAR: p. 22). and it concerns financing commitments prior to the Modus operandi: Common methods have been Ministry's submission of its budget to the Ministry developed for financial management, auditing, pro- of Finance. (See Timetable of Major Health Sector curement, management of logistics and technical Planning and Monitoring Events, President's Report, assistance, monitoring, and reporting. Common Schedule B, Table 1). In addition, a monthly Gov- implementation arrangements have been outlined ernment-Health Partners meeting keeps participants in a Memorandum of Understanding (MOU, 30 April updated about current issues and enables them to 1999) between the Government and donors.4 The discuss operational matters. Districts and regions re- MOU contains many of the provisions of the De- port quarterly on problems and accomplishments. velopment Credit Agreement with the Bank, includ- Before the end of 2001 a major evaluation of progress ing overall targets for Government financing of the of the POW is planned, including an explicit mea- health sector, exclusion of activities outside the agreed surement of health impact. Bank supervision focuses POW, appraisal of new capital projects, common on assisting the MOH and GHS with problem solv- procurement procedures, common disbursement ing, particularly on systemic issues and policy con- procedures, minimum "readiness criteria" for dis- cerns. This means the Bank must keep up to date bursement of funds to BMCs, appointment of an about how health services are operating at different acceptable independent auditor, and the annual levels, how beneficiaries are affected, and what other schedule of work. In addition, a "Code of Practice" partners are doing. The Bank sends teams to both is attached to the MOU that stresses sharing of in- semiannual meetings and conducts assessments and formation; increasing responsibility for technical spot checks on the measurement of performance in- assistance by the MOH; channeling all earmarked, dicators before the April meeting. It focuses particu- 'The Bank is not a signatory to the MOU since most of its provisions are included in the Development Credit Agreement. 62 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA larly on issues related to macroeconomic linkages, and the Bank are supporting the Program. All financ- health financing and procurement, areas in which it ing would occur within the boundaries of the POW; took a leading role in the preparation and appraisal the Government has agreed not to accept any financ- process. Other missions can be called by the Gov- ing outside this context. An IDA Credit for US$35 ernment and donors to deal with specific issues. The million provides a base amount of US$7 million per Bank also maintains a local resident mission pres- year. An interesting feature of the Credit is the pos- ence to keep abreast of sector developments and to sibility to vary annual disbursements in relation to continue the dialogue. performance. Conditions for baseline funding in- Procurement. The exact mix of civil works, good clude (a) the Government meets its fiscal commit- and services to be financed is based on the annual ments to financing the POW, and (b) audits of the plans of the POW. At the time of Board approval, POW demonstrate adequate fiscal probity (SAR, p. the Government and MOH were currently putting 18). If these conditions are not met, the Bank would into place procurement procedures acceptable to IDA decrease IDA amounts below the baseline. Flexibil- and other donors, in particular responding to the ity also exists to increase the amounts disbursed based recommendations of a Joint MOH-Donors Procure- on three additional conditions: (a) capacity to imple- ment Mission in October 1996. The memorandum ment the POW as measured by ability to spend ac- of understanding (MOU) outlines the common pro- cording to POW plans; (b) an increasing gap between curement procedures to be followed under the Health the budget and available grant funds in which case Account. Some donors would continue following IDA funds could be used to fill the gap; and (c) strong their own procurement procedures, but these prac- showing on the agreed set of sector performance tices would be phased out over time (SAR, pp. 24- indicators. In the future it is expected that financing 5). To focus efforts on improving sustainable will be explicitly linked to performance on agreed procurement systems within Ghana to cover mul- sector indicators (SAR, p. 18). Consistent with this tiple sources of funds, an independent third-party flexibility, Schedule 1 of the Credit Agreement leaves review would be the major source of procurement US$30 million of $35 million (86%) unallocated. review, rather than a review by the Bank. An a poste- Funds are available for all non-wage categories of riori third-party review would become the main expenditure except taxes and land acquisition. The method of review. However, IDA prior reviews would SAR describes the prospect of "gap filling" in exter- be applied to all international competitive bidding nal funds as IDA playing the role of donor of last (ICB) packages in excess of US$2 million, goods over resort. In view of the long-term nature of building $300,000 and consultant contracts over $100,000 if capacity in the health sector, the continuing need the financing involves IDA funds in whole or in part for external financing, and the long time required (SAR, p. 27). A procurement plan indicates the source to improve the health status of a population, IDA of financing. The Health Account, which includes could make a long-term commitment in the form IDA funds and others, is a source for some of the of a series of Credits. Upon disbursement of 75% of procurement contracts. It is not earmarked by the the existing Credit, the Bank would seek follow-up donors putting the money into the Health Account. Credits based on the evaluation of performance un- Nor can the individual donors be identified for con- der the POW (SAR, pp. 17, 33). tracts paid from the Health Account, except as a pro- Flow offunds and disbursements: A unique fea- portion of the funds. ture of the IDA Credit is the use of a common ac- Financing: The first five years of the sector pro- count and pooling of resources. The SAR states that gram is estimated to cost about US$825 million, of the MOH has gone a long way to establish financial which about US$200 million (24%) would be fi- management systems that will ensure appropriate nancedbyexternaldonors,70%bytheGovernment, use and accounting of funds (p. 22). The majority and the balance from cost recovery. Fifteen donors of donor funds, including the IDA Credit, will be 63 ANNEX 3: GHANA HEALTH CASE STUDY managed on lines of existing government procedures. the usual IDA withdrawal applications. Disburse- Some earmarked project funds will continue over ments are made approximately every quarter. (A con- the medium term, but the preferred donor financ- dition of disbursement includes the submission of ing system is an untied contribution into a common the annual MOH budget submitted to parliament. Health Account. Once IDA and other donor funds In addition, meeting the "Readiness Criteria" is a pre- reach the Health Account, there is no further iden- condition for the disbursement of Health Accounts tification of the funds by donor origins, thus the funds by the MOH to a BMC. In the view of Bank funds are genuinely pooled. (SAR, p. 23). IDA is put- staff the "disbursement issue" exists only because of ting all its resources into the pool. Three other do- Bank requirements. MOH regularly produces and nors5 are putting part of their contributions into the certifies the required financial statements. Other do- pool. The rest of the resources and those of other nors are disbursing on the basis of these statements donors are earmarked funds, but are not provided only. in the traditional manner, as they are planned ac- Auditing offunds: Under current procedures the cording to the annual planning and budgeting cycle, MOH is audited annually by the Auditor General and are channeled through the Financial Controller and this would continue under the project. In ad- in an accountable manner, rather than directly to dition, an acceptable private firm is hired under sub- program managers in isolation of other funding.6 contract with the Auditor General to provide The Health Account funds are put into a bank ac- verification that all payments out of the Health Ac- count under the direct control of MOH and the Con- count (not just donor funds) have been used in ac- troller and Accountant General. These funds are then cordance with the POW. Major BMCs are to be distributed to all eligible BMCs that meet minimum audited each year and others at least every three "Readiness Criteria", including: (1) submission of years depending on size. An acceptable audit re- annual budget accompanied by quantified targets and port each year, by July 1, is a condition for mainte- objectives; (2) satisfactory procedures and collect- nance of Bank funds at the base level for the ing and accounting for independently generated following year. Independent audits have been con- funds; (3) adequate procedures for authorization of ducted on finances, financial management, and pro- payments; (4) adequate and timely maintenance of curement. It is worth noting that these audits cover accounts; and (5) adequate staff and procedures to all HSSP funds and procurement, not only donor prepare monthly reports on revenues and expendi- contributions. tures (SAR, p. 24). Risks: The SAR identifies several risks associated One of the issues in program development was with financing the HSSP. First, decentralization of whether to reimburse against receipts or disburse budgeting and financial management risks misman- against outcomes. The latter is the intention, but the agement of donor (and Government) funds, par- former is the transitional arrangement. IDA reim- ticularly in view of the limited experience of BMCs burses expenditures already incurred out of govern- in managing funds. This risk is minimized by limit- ment funds for the health sector based on the ing allocations to a set of BMCs that are certified to submission of financial management reports under manage funds based on their capacity and auditing the POW, including supporting documentation for them regularly. Second, the Government may not 5 Dutch assistance, DANIDA and DFID. 6 However, the Code of Conduct states that these earmarked funds should be channeled through the Financial Controller rather than directly to program managers so as to enable the MOH to track total donor contributions and assist with annual planning and budgeting. 64 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA maintain its financing commitments to the POW, SWAP IMPLEMENTATION or may introduce questionable capital expenditures. This risk is managed by the provision to respond in Implementation experience: As indicated in the Bank the worst case (short of suspension or cancellation) supervision report7 following the second annual re- by decreasing the amount to be allocated that year. view the Government has made good progress in Third, there is a risk that common implementation implementing the POW. The Government has in- procedures with donors may not work. To deal with creased the percentage of the total recurrent bud- this risk a regular Government-donor forum has get spent on health from 7% in 1996 to 8.4% in 1997 been established to monitor progress, and a MOU and 8.6% in 1998-in accordance with POW tar- clarifies responsibilities. An informal Code of Con- gets. This was accompanied by a shift toward more duct has also been drafted for guidance in other ar- decentralized funding and increase in internally gen- eas of interaction. erated funds. The public health services have shown Annan identified some local perceptions of other improvements in terms of vaccinations and family risks in SWAPs: (a) "failure of policy dialogue could planning services and a recent increase in outpa- lead to a form of 'gridlock' for the sector; (b) donor tient services. Noticeable progress has been achieved influence could increase as a result of joint reviews in financial management and most of the 1998 ob- and closer monitoring of policy outcomes; (c) flex- jectives for procurement services have been achieved. ibility and responsiveness could be limited due to The extensive review of performance in 1998 re- the 'blueprint' nature of the program which, in es- ported that "significant steps continue to be made sence, is not an evolving strategic plan; and (d) do- to shape the reform process in policy and strategic nors not involved are likely to perpetuate the terms and in capacity building, and in service de- problems of fungibility of aid and overburden gov- livery most of all." However, in other respects 1998 ernment management capacity" (p. iv). was a difficult year. The Minister of Health, the Di- Conditions: The Government agreed during rector of the Medical Service, and other persons re- negotiations to take all actions to increase the lev- sponsible for the reforms changed during the year. els of its expenditures on the health sector as agreed In addition, a review of the capital budget led to within the POW, including not less than 6.9% of protracted disagreements over two hospital devel- Government recurrent expenditures in FY1997, opment programs. In the end an agreement was 8.6% in FY1998, 9.5 percent in FY1999, 10.0 per- reached on the hospital rehabilitation projects (one cent in FY2000, and 11.0 percent in FY2001. It also being kept at the original allocation of $12 million agreed to subject all proposed capital projects to and the other being re-assessed.) However, the dis- appraisal according to agreed criteria; to submit agreement and some administrative delays prevented an annual implementation plan and budget prior some donors from disbursing into the health ac- to the annual meeting with donors in September count. Donor contributions to earmarked programs and review progress on the previous year's health were actually less in 1998 than in 1997. Despite these plan; submit reports and financial statements cov- difficulties, the program has been implemented ering achievement of indicators and use of POW largely on schedule. Based on overall positive results, funds before April each year for the joint Govern- the Bank team recommended consideration for in- ment-donor review, and lead a major evaluation creasing the IDA allocation for FY2000 from the of the POW before the end of the fifth year (SAR, baseline amount of $7 million to $9 million, pend- pp. 32-33). ing issuance of the final procurement and financial Francois Decaillet, Back-to-office report, June 1, 1999. 65 ANNEX 3: GHANA HEALTH CASE STUDY audits for 1998. The annual review was informed (5) The review of other donor-assisted projects by an excellent comprehensive report prepared that fall outside the agreed program was an jointly by the Government and outside experts. awkward and difficult process for donors, People from the opposition party participated in the who are not accustomed to influencing the Health Summit in 1999. Other points include the exclusion of projects supported by other following: donors. (6) Another event during implementation that (1) Both annual reviews have commented upon has the potential to slow reforms has been the difficulties of getting good information a strike by young doctors. Resolving the on the indicators, although data for 1998 strike became a priority for the Government were much better than 1997. There was some and the donor consortium also had to be dissatisfaction expressed about the indica- concerned with the issue. Normally, with a tors used and a need for a "thorough revi- project approach, the donors would not con- sion of these indicators to improve the sider such events if they did not impinge performance contract system" (Supervision on the specific projects being financed. report, p. 2). (2) It has taken longer than expected to get an The coalition survived the change of the minis- acceptable Government procurement plan terial team, a conflict over the capital development and reach agreement with the Auditor Gen- program (Tamale and Koforidua hospital), the very eral about an independent auditor. The AG turbulent situation created by unrest in the sector did not want outside interference. Eventu- (strikes for better condition and against the milita- ally agreement was reached on a one-year rization of hospitals in Accra), and the presentation contract with a private firm rather than a of the procurement audit, which revealed some three-year contract as envisaged in the docu- anomalies. An open, pragmatic, and cautious ap- ments. proach to dialogue is making this coalition strong. (3) An issue has also arisen in terms of incon- sistency between the intention of using (im- proved) government procedures for OUTCOMES SO FAR procurement so as to build capacity, and the Development Credit Agreement that calls Main achievements: for Bank control of all procedures. The is- sue pertained to initial implementation, but (1) As noted in the Appraisal Report, a major has reportedly been resolved since receipt benefit of the sector approach is already seen of the procurement audit report. It is now in improvements in the processes and results clear that the Bank' s role is not to control, of policy dialogue and health sector plan- but help MOH to strengthen its own pro- ning. For the first time health policies are curement and control capacities. being explicitly linked to resource allocation (4) A compromise was reached that reimburse- in a comprehensive manner, covering all ments will be made against receipts and Government and donor financing. The sec- normal withdrawal applications; and that tor approach has brought a more rational procurement will be controlled by the Bank. policy discussion and improved transpar- At the end of the year, and based on audits ency and accountability. (SAR, p. 30). of both finances and procurement the pro- (2) During the development of the sector-wide cedures will be reconsidered. The Country program the Government defined for the Director can authorize changes. first time its overall capital program for the 66 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA health sector. After an initial agreement with Policy and Standards since 1996. However, donors on a capital program of US$230 they remain largely unimplemented. million with priority given to primary health "> Quality of care: Quality assurance teams are care, other parallel capital investments functional in five of the nine regional hos- emerged that were outside the agreed pro- pitals and partially functional in one other. gram. These included the construction of Quarterly monitoring of quality assurance regional hospitals financed by commercial indicators has been carried out in several loans and supplier credits. The total capital regions. investment ballooned to $509 million and distorted the balance among levels and types Main problems (or lack of achievements): of health care, and between planned recur- Specific issues identified during the 1998 annual rent and capital expenditures. This became performance review include: a significant part of the macroeconomic dia- logue between the Bank, the IMF, and Gov- > MOH institutional capacity: (1) There is a ernment, which eventually led to revisions backlog of policies, strategies, plans, and of the capital program. A capital program protocols that have not been implemented. of US$298 million was finally agreed on (2) The Management Information System between the Government and donors (SAR, has not been able to deliver timely and use- p. 15). In addition, new procedures for ap- ful information. (3) Plans developed by the praisal and procurement of capital programs MOH show evidence of weak planning ca- were agreed on to prevent such occurrences pacity. (4) Many important policy issues in the future. This potential distortion in have not been addressed. overall capital expenditures would not have c Deconcentration of resources toward the first been picked up without a sector-wide ap- level of care is progressing. proach (SAR, p. 3 1). However: (1) There are neither benchmarks against which annual performance by the Ghana is in the early stages of implementing districts is evaluated, nor a formula to as- many of its reforms, so it is still early to judge their sure funding equity. As a result, the alloca- impact. However, there are already indications of tion of resources is based on historical progress in the 20 annual performance indicators. precedence rather than outputs, outcomes, (See Table.) Independent reviews of sector perfor- or need. (2) Operating costs at the first and mance have also found the following progress and second levels of service remain highly de- problems: pendent on user charges and external aid. + Decentralization: The process has stalled • Transparency: The level of transparency has because of controversy in both the legal and greatly increased as a result of the annual political arenas. Establishment of the Ghana review process. In addition, independent fi- Health Service has stalled because of unre- nancial and management audits of the solved issues between the DHMTs and the MOH were conducted in 1997 and 1998, and local government system regarding planning will continue to be conducted annually. authority and financing responsibilities. Po- • Reproductive health: The number of family litically, the issue involves disagreements planning "couple years of protection" has about responsibility for overall development increased. Knowledge and support for re- and supervision of services at the local level. productive health are high, and Ghana has ... Performance-based contracting: Although the had National Reproductive Health Service format for agreement between the MOH 67 ANNEX 3: GHANA HEALTH CASE STUDY and the Mission hospitals was approved, and it can take the time to discuss and address 21 out of the 43 hospitals met financial the sectoral issues. readiness criteria in 1998, no contracts be- (4) Stability is also needed on the donor side tween the government and hospitals were to afford time to build up confidence developed. Despite this, the government has among the donors themselves, and with continued to make payments to the Mission the Government. SWAPs cannot be devel- Hospitals. oped in a "stop and go" context. s Demand side issues: Supply side aspects of (5) The Ghana Health SWAP grew out of cir- service provision have been the primary fo- cumstances that were almost unique. It cus, and few efforts have been made to gain cannot be transposed elsewhere. For ex- an understanding of the determinants of uti- ample, the progress toward pooling of lization or of how to improve access for donor funds is built upon significant in- women and the poor. vestments in financial management sys- tems and supervision that may not exist elsewhere (Peters and Chao: 184). OBSERVATIONS (6) A SWAP does not have the security of a AND POSSIBLE LESSONS traditional project, where content and quantities are well defined in advance. In- The Ghana Health Sector SWAP was the first SWAP stead, the security must be implicit in the in the social sector to encompass a whole sector, and procedures by which decisions will be it goes furthest in pooling resources and using gov- made during implementation. ernment procedures. (7) It took time to get implementation orga- nized after the start of the program, in- (1) It is important for donors to avoid resent- cluding agreement on independent ment for undue intervention in the auditors,andthepreparationofaprocure- Government's affairs in a sector approach. ment plan. Implementation issues were The donors should recognize that they do considered at the design stage but, under- not determine decisions. The Government standably, they received less attention than is in the driver's seat and does what it wants agreements on policy, program content, ultimately. Donors should react to what and definition of indicators. It is impor- Government proposes rather than taking tant to recognize in advance the need for, the initiative. SWAPs are possible if donors and accelerate work on, key implementa- do not stick to their own vision or pet ideas, tion activities. but see themselves much more as brokers (8) The annual system of reports, reviews, and/or skeptics. The donor role is chang- budget planning, and revisions in the pro- ing as the national policy capacity in- gram needs to be planned in detail. Terms creases. of reference for the reviews, and joint re- (2) It took longer than normal to prepare the sponsibilities were determined in ad- SWAP for donor financing, largely because vance. They were changed several times of the number and breadth of issues to be before and during the reviews themselves. resolved and because of specific disagree- Similarly, the quarterly reports and bud- ments over the affordability and desirabil- get systems were also designed ahead of ity of the capital program. time, and used before the project was ef- (3) SWAPs need a context in which the gov- fective. The importance of having worked ernment is strong and has stability so that out mechanisms and responsibilities is 68 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA underscored. It is very important to have (11) One observer stated, "Because of its na- a system in place by which views by all tional perspective and wide scope, the sec- parties can be aired and disagreements re- tor-wide program is less likely to promote solved. In the end it is not so important participation at the local level and broaden that disputes and differences occur so long ownership through the current implemen- as a process of mutual consultation is in tation processes" (Annan: iii). However, place and methods have been agreed in ownership is actually determined by the advance on how to resolve disputes and type of reforms put into place. In this case, solve problems."7 increased resources and authorities went (9) It is not enough to prepare a set of indica- to local levels, along with increased ac- tors by which to measure performance. A countabilities and needs to involve users system must also be in place to collect the of health services locally. information, analyze and report on it. Even (12) "Strong local leadership of the SWAP pro- this is often not enough. There must be a cess is required, but this may initially in- place to conduct dialogue over the results. volve a few committed actors. It is, however, Health summits offer this venue. Bank staff essential for external partners to recognize found it highly stimulating to see various early the need to progress from support stakeholders (MOH HQ and regions, NGO to, and dialogue with, individuals and small and the minority representatives) discuss- groups to a wider institutional involvement ing the review results. that will ultimately build capacity for a (10) Under a sector-wide approach the donors larger group of professionals and provide need to keep in touch with all develop- greater scope for skills" (Annan, p. 28). ments in the sector. It is easy to miss im- portant topics, such as not looking sufficiently at the private sector-an ac- BIBLIOGRAPHY knowledged gap in the design of the HSSP. This has several implications: (a) a local Annan, Joe. 1999. "Ghana Health Sector-wide technical presence may be necessary to Programme: A Case Study." JSA Consultants, keep the dialogue going; (b) more frequent Ltd., Accra. Prepared for DAC I/CD Network and missions may be needed; and (c) better Policy Branch of CIDA, April 1999. capacity is needed by donors to analyze Decaillet, Francois. 1999. "Ghana: Health Sector the issues and present alternatives, requir- Support Project-Back to Office Report." June ing different skills than heretofore has 1,1999. been the case with most donors - e.g., Peters, David, and Shiyan Chao. 1998. "The Sector- policy analysis and an ability to present Wide Approach in Health: What Is It? Where Is and negotiate recommendations on policy It Leading?" InternationalJournal of Health Plan- issues. ning and Management 13: 177-190. 8'Comments on this by project staff involved include the following: In hindsight, it would have been preferable not to air all disputes in a large open forum-this led to increased rigidity and some posturing that may have been worked out through other means. Instead of spending years designing a process for mutual consultation, it should be tried out. Good, willing people are more important than procedures. Instead of rewarding the elaboration of procedures, one should develop a system to reward people for solving problems. 69 ANNEX 3: GHANA HEALTH CASE STUDY Republic of Ghana. 1998. "Memorandum of Under- for a Health Sector Program Support Project." standing: Ghana Health Sector Programme of Report No. P 7179 GH, September 25, 1997. Work." April 30. World Bank. 1997. "Staff Appraisal Report: Repub- Republic of Ghana. 1999. "Health Sector 5-Year lic of Ghana Health Sector Support Program." Programme of Work 1997-2001: 1998 Review." Human Development III, Ghana Country De- Ministry of Health, Accra, April. partment, Report No. 16467-GH, September 25, World Bank. 1997. "Memorandum and Recommen- 1997. dation of the President of the International De- "Aide Memoire: Joint Ministry of Health-Health velopment Association to the Executive Directors Partners Summit Meeting (May 5-7,1999), Re- on a Proposed Credit in the Amount Equivalent view of the 1998 Programme of Work." 7 May to SDR 25.1 Million to the Republic of Ghana 1999. 70 EDUCATION AND HEALT'll IN SUB-SAHARAN AFRICA TABLE 2 Progress in 20 Annual Performance Indicators Indicator 1 1996 Baseline 1997 1998 1. Percentage Government of Ghana 7% 8.4% 8.6% recurrent budget spent on health. 2. a) Recurrent Level GOG DONOR IGF GOG DONOR IGF GOG DONOR IGF expenditure by level Headquarters 28.1% 29% 2% 5% 27% 0% and source Tertiary (ITEMS 2-5) institutions 31.5% 22% 30%1o 22% 4%/o 94% Regional 17.1% 15% 2% 13% 30% 0% District 23.3% 34% 66% 60% 39% 6% 2. b) Capital expenditure Headquarters 53% 25% N/K N/K by level and source Tertiary inst. 11% 20% N/K N/K in % (items 7-9) Regional 34% 27% N/K N/K District 2% 28% N/K N/K 3. a) Percentage Budget Headquarters 47.6% N/A and Management Teaching Hospitals 100% N/A Centers with budget Psychiatric Hospitals 100% N/A and plans. Reg. Health Admin. 100% 1000%u Regional Hospitals 100% 100% Health Training Inst. 89% 100% District Health Admin. 100% 100% District Hospitals 76% 98% Sub-districts 63% N/A 3. b) Meeting readiness criteria: 57% 57% 4. Percentage Budget and Management 50% 63% 100% Centers with quarterly income and expenditure returns. 5. Contracts for mission hospitals, NGO and Being developed as Memorandum of None. private service providers developed and in use. part of the Understanding performance developed and monitoring system. consensus meeting held with Mission Hospitals. 6. Dlevelopment of a Goods Bidding document Procurement unit PU Established single set of procurement developed. (PU) set up. Procurement Manual procedures. developed and adopted. Civil works Draft guidelines pre- Options appraisal In progress. pared. applied to major capital projects. Technical assistance Draft guidelines devel- Standard Bidding oped. List of TA pro- Document completed curement for 1998 List of TA for 1999 prepared. prepared. (contintued on the next page) 71 ANNEX 3: GHANA HEALTH CASE STUDY TABLE 2 (continued) 7. a) Completion of Regional level BMCs Estab. for tech staff 100% completed. 100% staffing establishments completed. for BMCs. Headquarters BMCs 80% subject to redefi- 100% nition of Organigram Statutory bodies None completed. None completed. Process ongoing. In progress Tertiary level BMCs 40% completed. New 80% BMCs yet to be done. 7. b) Percentage BMCs with 90% to 105% staffing Regional level BMCs N/A establishment filled. Headquarters BMCs 100% Statutory bodies Tertiary level BMCs N/A 8. Percentage districts with Greater Accra 60% 100% communicable disease Eastern Region 80% 100% surveillance reports. Central region 70% 100% Western Region 60% / 80% Volta Region 80% / 75% Ashanti Region 70% 100% Brong Ahafo Reg. 90% 100% Northern Region 80% N/K Upper East Reg. 100% 100% Upper West R. 100% 100% 9. Outpatient ) 1 0 __ 100%A visits Ashanti 1390704 643417 747287 1334441 615292 719149 1399110 N/A N/A Brong Ahafo 830982 384218 446764 970335 447423 522912 923773 N/A N/A Central 275262 148512 127740 337401 160072 177329 410344 N/A N/A Eastern 758755 320184 713993 292736 438571 739894 N/A N/A Greater Accra 1258041 504449 753592 1277251 538900 738351 1215489 N/A N/A Northern 273563 143437 130126 364480 178400 186080 364649 N/A N/A Upper East 297905 142560 155345 173937 85184 88753 194338 N/A N/A Upper West 130471 68639 61832 152810 79263 73547 161383 Volta 530604 235267 295337 565485 240150 325338 658280 N/A N/A Western 603398 277844 325554 656637 304560 352077 686102 N/A N/A National 6350675 2868527 3482148 6546773 2941980 3604793 6753363 N/A N/A OPD visits 0.36 0.36 0.35 per year 10. a) Hospital ' . a a p M f P e Female admissions Teaching Hospital 80979 92528 ' 91987 N/A N/A Regional Hospital 354688 392531 389337 N/A N/A and District hospitals Per 1000 pop 25.0 26.5 25.5 72 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA Indicator 196 Baselne 1"7 198 10. b) Bed LEVEL PUBIIC PUBLC PUBLC, occupancy Teaching Hospital 90.8% 91.3% 91.7% Regional Hospital 70.1% 70.8% 71.5% District hospitals 65.2% 67.2% 71.3% 10. c) Average Teaching Hospital 8.5 8.2 7.5 Regional Hospital 7.4 7.2 6.3 District hospitals 7.8 7.5 5.2 11. EPI DPT3 51.4% 59.6% 67.5% coverage OPV3 53.2% 58.5% 67.5% 12. Family planning - 251,762 (6.0%) 264,412 (7.7%) 346,523 (9,2%) Couple years protection (% CYPs of no. WIFA) 13. Percentage children using Less than 1% Less than 1% Less than 1% bednets 14. Condom sales 2,230,900 2,126,171 2,105,716 15. Percentage tracer drug (80%) (86.8%) CMS 87% availability/essential drugs RMS: 92% stocked at the district level DMS: 90% Health Facility: 83% 16. Medical equipment 60% 70% N/K performance index 17. Average District hospital ˘27,500 ˘14,347 cost per Regional hosp. ˘33,000 435, 848 inpatient day Tertiary hospital ˘39, 009 18. Amount spent on CATEGORY 199"6 997 1998 exemptions by Paupers N/A N/A ˘ 390 m. exemption category Antenatal Services ˘2.6b 4 1,515 m. Aged (over 70) 40.7b ˘ 429 m. Children (under 5) - 54 m. Psychiatry/Leprosy 42.8b N/A Emergency cases ˘ 153 m. Others ˘ 0.4b 4 191m. 19. Number of outreach Ashanti Region 5 5 clinics by region Brong Ahafo Reg. 6 6 7.6 (average number of Central Region 10 10 14.2 sites per health facility) Eastern Region 8 9 5.3 Absolute number of Greater Accra 9 9 16.2 outreach sites, by year: Northern Region 11 11 14.7 1996 . 6,677 Upper East Reg. 5 7 7.0 1997 . 7,436 Upper West Reg. 8 9 11.9 1998 . 10,249 Volta Region 5 8 17.9 Western Region 6 7 9.2 National (average) 7 7.7 11.1 20. Percentage district, Teaching Hospital 0% 0% 0% regional, and teaching Regional Hospital 22% 33.3% 56% hospitals reporting on District Hospital 13% 33% 10% patient satisfaction. 73 ANNEX 3: GHANA HEALTH CASE STl UDY TABLE 3 949 - Ghana, Health SCTR Support Project Status Report Date: 6/11/99 Region: AFR Country: GHANA Sector: HH Lending Instr: SIL Prg Obj Cat: PA EA Cat: C PTI? N NGO? Y Resettlement? N LOAN INFORMATION Agree I/C/G Rev'd Currency Prod Signing Effective Suppl Prj Type No. OrigAmt Amt Indicator Line Date Date ID IDA 29940 25.10 (SDR) PE 4/3/98 6/18/98 Total Original Amount (SDR): 25.10 Total Revised Amount (SDR): 0.00 COFINANCING INFORMATION Agency Board Amount ($M) Current Amount ($M) ADF 4.40 BADEA 4.50 CIDA 0.20 DANIDA 30.10 DIGIS 9.60 EU-EC 9.00 GTZ 4.50 JICA 0.90 ODA 47.00 OPEC-SF 5.00 PRIVATE 77.00 SAUDI F 2.30 UNFPA 10.00 UNICEF 10.00 USAID 12.00 WHO 4.30 Total 0.00 230.80 Guarantee Type: Guarantee Amount ($M): This form is part of: Portfolio status update Read together with: Aide-memoire Mission End Date: 5/13/99 This Form PSR Date: 6/11/99 BTO memo of: Months since last mission: 9 Last Form PSR Date: 2/3/99 Follow-up letter of: Next mission planned: 9/15/99 Total Field SUPERVISION Staff- Total Staff- Field As of EFFORT Weeks $000 Weeks $000 6/11/99 Current FY - Planned 58.40 121.84 Current FY - Actual 55.68 127.37 0.00 0.00 Board through preceding FY 16.88 75.65 0.00 0.00 Total Actual 72.56 203.02 0.00 0.00 No. of Role or Previous UPI No. Mission Member Division Fld Days Specialization Mission 66828 DECAILLET AFTH3 12.0 PUBLIC HEALTH, TTL Y 74 ANNEX 4 Senegal Health Case Study' Integrated Health Sector Development Program (IHSDP) BACKGROUND by a multitude of donors. All parties realized that this fragmented approach was not conducive to the IDA financed a multi-sectoral human resources de- development of the sector as a whole. Government velopment project (PDRH1) in 1991 for US$35 was not in a position to coordinate the activities of million. The health component, implemented in all donors. There was no single policy or vision for three regions, highlighted the need for the consid- the sector. The Government was ready to adopt a eration of human resource management issues in sector-wide approach and willing to take the lead the context of civil service reform, and the impor- in its development. tance of building the capacity of the central admin- istration in the context of decentralization. The impact of change initiated under the PDRH 1 project SWAP DESIGN and the sectoral studies it helped finance, enhanced the Bank's policy dialogue with Government on Basic data: Kind of lending instrument: Sector In- health sector development. It also paved the way for vestment Loan (SIL). The elapsed time for program significant reforms in health financing and the de- development was 85.7 weeks (from Concept Review velopment of a comprehensive framework for im- to Decision Meeting). The time between appraisal proving health system management, decentralized and Board presentation was 14.9 weeks (see attached management, and the promotion of health insur- data sheet). ance. Sectoral studies under PDRH1 raised four criti- Rationale for the SWAP: The main impetus for cal issues for the health sector: (1) inadequate and the SWAP was the lack of performance and impact inequitable financing of curative care; (2) low effi- on sector-wide issues from the classic project ap- ciency in the use of resources by public sector health proach. The country had been divided into a mo- facilities; (3) low utilization and access to health care saic of small projects (over 20 projects) that did not and family planning services; and (4) inadequate hu- add up to an impact on overall sectoral issues. There man resources and lack of effective human resource was a general recognition that many of the issues in development in the sector. the sector were system-wide (such as administration, The background to the SIP is also character- human resources, financial sustainability) and could ized by a proliferation of health projects financed not be addressed in an insular, piecemeal fashion. ' Based on an interview with Mr. Anwar Bach-Baouab, Task Team Leader, and the Staff Appraisal Report, No. 16756-SE, August 8, 1997. 75 ANNEX 4: SENEGAL HEALTH CASE STUDY "The issues facing the sector are systemic and re- ingness of the Ministry of Finance to work hand in quire a broader systemic response" (SAR, p. 17). As hand with the MOH in designing the program, which further stated in the SAR, "The issue of a traditional augured well for success in program implementa- investment project versus a broader sectoral invest- tion. The Ministries of Health and Finance estab- ment program was thoroughly discussed with Gov- lished a National Task Force composed of highly ernment and donor agencies during the program motivated members from both ministries. This Task identification and preparation stages. The decision Force was the driving force behind program design. to move forward with a sector approach is based on: Technical support was provided by donors during (a) the willingness of donors to participate in a sec- the program design process. Donors were given the tor investment program and support implementa- opportunity to review and comment on draft ver- tion of the Government development plan, and (b) sions of the program documents. commitment of the Government to define a long- Donor coordination: The European Union (EU) term policy framework which addresses all key is- was the lead agency for donor coordination. One of sues of health financing, efficiency and sustainability. the major elements for the success of the program In addition, implementation of the health reform was that the Bank did not take the lead among do- agenda initiated in 1991 was well sustained during nors. The Bank was not seen as driving the process. the past five years. ... This has laid the foundation The EU convened regular monthly donors meet- for a comprehensive reform of the health sector in- ings and maintained official correspondence with volving all major stakeholders" (pp. 15-16). the Government. In contrast with the past, a sys- SWAP characteristics: The program is sector-wide tematic sharing of information was achieved. Also, in scope; it is based on an agreed sector policy and donors made an effort to associate other donor part- strategy; it is founded on an agreed expenditure pro- ners in the program so as to work in a complemen- gram; the Government clearly has leadership of the tary manner. process; all main donors have agreed to the program Program development: (1) The National Task and to finance a share of its costs. Force first agreed on an action plan for the design Preconditions: Besides a favorable macroeco- of the program. (2) The second step was to under- nomic environment, the following pre-conditions take a series of studies on the assessment of human were met for starting to develop a sector-wide ap- resources, health financing, hospital reform, assess- proach: (1) Government commitment and willing- ment of primary health care, and cost recovery. Do- ness to take leadership; (2) donor commitment to nor funds were readily available to finance these the sector-wide approach; (3) clear strategic vision studies. (3) Third, based on the findings the Task by the Ministry of Health; and (4) a minimum in- Force developed a "Long-Term Strategic Vision for stitutional capacity as indicated by the implemen- Health Development." (4) Fourth, the Task Force tation of previous projects. then developed a 10-year National Health Plan, Definition of the sector: The Health Sector Pro- which identified critical priorities and implemen- gram is not limited to any aspects but encompasses tation mechanisms with technical support from mul- the overall health system: primary, secondary, and tilateral and bilateral donors and involving extensive tertiary health care. It focuses on two major generic consultations with stakeholders. Government own- issues for the sector: human resource development ership of the design process was strong, with MOH and health sector financing. Thus, the "sector" is con- being the driving force behind the process. (5) The gruent with the existing management organization long-term plan then led to the preparation of a"Five- for planning and budgeting. Year Action Plan" that spelled out immediate pri- Program leadership: The Ministry of Health orities and investment requirements. (6) The (MOH) led the process of program development. Ministers of Health and Finance convened a One of the successes in the operation was the will- roundtable of donors at which the Plan was reviewed 76 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA by donors and pledges were made for the financing the Five-Year Action Plan. In the end there were no of the Plan. This resulted in a well-conceived financ- major disagreements on policies or strategies. ing plan, including both national and external sources. (7) Program appraisal came right after the roundtable. Key program documents (strategic THE IHSDP PROGRAM framework /long-term plan /and medium-term ex- penditure program) were reviewed and commented Aims and content: The IHSDP seeks to improve the on by donors at regular intervals in the program quality, access, and sustainability of health delivery design process and officially endorsed at the systems as a means to improve the health status of roundtable. In the process as a whole there were few the population and accelerate transition toward disagreements of a substantive nature. Differences slower population growth. The Program will (1) ex- centered mainly on administrative and financial pro- pand access to primary health care and referral ser- cedures. vices to the majority of the population; (2) improve Level of sector analysis: The prior IDA project, the quality, efficiency, and effectiveness of health care PDRH1 (Human Resources Development Project) provision including reproductive health information financed several sector studies that formed the basis and services, and (3) strengthen the MOH institu- for the IHSDP. In addition, in the design of the Pro- tional capacity to efficiently organize, monitor, and gram new studies were carried out in the areas of evaluate health services. In particular, the Program health financing, institutional development, hospi- includes hospital reform, restructuring of the Min- tal reform, reproductive health, and human resources istry of Health, decentralization of planning and development. These were also financed relatively management of health services to districts, and a quickly under the ongoing operation, which greatly comprehensive training plan for health staff. facilitated program design. Financing: The discussions on the Five-Year Ac- Institutional capacity: International experts were tion Plan and pledging, by donors yielded a good employed during program design to assess the or- overall financing plan. During pledging, coverage of ganization, structure, and administration of the at least the first two years of the program was stressed. health system. Recommendations led to the adop- The third and fourth year of implementation would tion of an institution development plan and a pro- be taken into account later. This introduced flexibility gram of reform, including a plan for restructuring in the financing. Some donors could pledge now or the Ministry of Health. In addition, the Program em- later for future years of the program. The total cost phasizes measures for staff recruitment and train- of the five-year program was estimated at about $410 ing at the district level. million, including both investment and recurrent Stakeholder consultation: Program development expenditures. External donors were expected to fi- followed a highly participatory approach. The views nance about 30% of the total cost and-within this of NGOs, civil society, associations of physicians, and -the IDA Credit of US$50 million would finance pharmacists and different ministries were solicited about 12% of the total cost. Fourteen donors will through a series of workshops and debates on the participate in funding the program.2 The Bank is the national health plan. This achieved a wide consen- donor of last resort. At appraisal the amount of the sus on the contents when the final plans were pre- Credit was determined on the basis of the size of the pared. The same was true for the development of expected gap in program financing. The Bank iden- - AfDB, the EU, IDB, NDF, JICA, KFW, the Kingdom of Belgium, the French Cooperation Agency, the Netherlands Coop- eration, Taiwan, USAID, Unicef, UNFPA, and IDA. 77 ANNEX 4: SENEGAL HEALTH CASE STUDY tified the program elements that were not taken by administration to local government; and (4) unfore- other donors in the first two years and specified those seen economic difficulties slowing or reversing in- for its initial financing. The balance (about 61 %) of creases in health expenditures. the Credit proceeds are left unallocated to allow flex- Conditionality: Very few conditions are attached ibility for adjustment in years three to five of pro- to the IDA credit. The process of Program design gram implementation. The Bank will pick up the led to widespread consensus and commitment to the financing of components left after other donors have reforms adopted in the Program. Specific assurances chosen, provided the Bank is satisfied that all pro- included: (a) actions to increase overall health ex- grams of high priority are being financed. penditures to 8.2% of total public expenditures by Procurement: Procurement under the program 2002; (b) financing of the Program in accordance is rather similar to that under a traditional project, with the agreed financing plan; (c) submission of but donors agreed on a common procurement plan work programs and budgets at least three months that identified their respective input and timing. before the joint annual review; and (d) submission Financialflows and disbursements: Considerable of progress reports on agreed performance indica- discussion took place among the donors during Pro- tors and use of funds before the joint annual reviews gram design about "basket funding", or the pooling (SAR, p. 47). Conditions, thus, focus mainly on the of resources. It was clear from earlier SIPs in the process for annual review and adjustment of the pro- health sector (Zambia, Ghana) that pooling re- gram. This review process was designed to be flex- sources was problematic. Therefore in the case of ible, with a self-adjusting process, so that allocations Senegal it was decided to adopt a flexible approach. could be adjusted each year in relation to perfor- Funds are not forced into a single basket. Basket mance and prevailing conditions. No separate rem- funding was included at the district level for recur- edies were considered necessary. rent expenditures, with donors making their con- tribution into a single district account using advances of funds or reimbursement mechanisms. However, SWAP IMPLEMENTATION the bulk of the financing is parallel funding. The donors contribute to common accounts, but ar- Organization for implementation: The MOH is re- rangements have been made so that each donor in- sponsible for overall implementation of the Pro- put can be identified and disbursements are kept gram, through its Directorate of General separate for accounting purposes. The process re- Administration, Finance and Equipment (DAGE) portedly has worked well and has enabled funds to and Technical Divisions. A special Support Unit be channeled to districts. The operation is regarded (SSU) was created at the cabinet level within the as a first generation of SWAPs, a step toward transi- MOH to oversee the management of resources pro- tion to eventual budgetary assistance. Before that vided under the Program. occurs, however, considerable strengthening will be Modus operandi: As stated in the SAR, "the needed in the Government's administrative and Sectoral Investment Program initiative adopted for management procedures to enable a majority of the IHSDP emphasizes a continuing policy dialogue donors to use them. and phased funding, based on yearly operational Risks and dangers: There are no special risks as- plans, ... eligibility criteria for program resources sociated with this SWAP in terms of approach. The and sector-wide performance indicators. ... This four risks mentioned in the SAR are: (1) slower than would be achieved through joint Government/Do- expected change in fertility; (2) continuation of weak nors annual implementation reviews" (Summary). implementation capacity at the MOH compounded The joint annual reviews are the key element in the by difficulties in staff recruitment and retention in implementation process. "The program will be the regions; (3) difficulties in the devolution of health implemented through a series of joint annual agree- 78 EDUCATION AND HlEALTH IN SUB-SAHARAN AFRICA ments based on assessment of previous years per- in practice. This has slowed the overall implemen- formance and operational plans and budgets based tation of the Program. Another implementation is- on priorities and established eligibility criteria for sue, not surprisingly, is the limited implementation access to program funding. This procedure will al- capacity at district levels. The Program includes as- low Government, IDA and other financing insti- sistance for recruitment and training of staff, but the tutions to adjust to changing conditions and impact has not been immediately felt at the district performance thereby building in a higher level of level. flexibility which will allow for more realistic plan- ning on a year by year basis" (SAR, p. 21). Plans call for five such annual agreements, each covering OUTCOMES SO FAR one fiscal year from 1998 to 2002. Each will sum- marize the detailed individual agreement for spe- Main achievements: So far the successes include: cific categories of expenditure. Annual reviews are (1) the political commitment and Government own- timed to coincide with the Government's fiscal year. ership for the overall policies, strategies and program; Monitoringandinformationsystems,commonfor (2) donor cohesiveness and shared approaches; all donors, are a key to the success of annual re- (3) an agreed strategic vision and framework that views. Two sets of data are collected: (a) Critical addresses critical issues; (4) a comprehensive, sys- performance benchmarks: for the first two years tem-wide, and national approach rather than the these include placement of program management focus on small elements of the system; (5) accom- staff, acceptable allocations to each expenditure cat- plishment of a participatory approach, including the egory, levels of disbursement, recruitment and signing of six major contracts with NGOs for the training of staff, and having MIS in place in all dis- implementation of health service delivery; and tricts. (b) Performance indicators for districts in- (6) adoption of a common financing, implementa- clude: increase in the use of health facilities, tion, and procurement plan by the donors and the proportion of children vaccinated, increases in pre- use of common indicators, supervision, and report- natal consultations, and increases in contraceptive ing procedures. prevalence. Itnpletnen tationi experience: Two mid-year re- views and one annual meeting have been held with LESSONS strong Government/Donors/Stakeholders participa- tion. The experience thus far has revealed certain The following lessons should be noted: weaknesses. First, the management information sys- tem is not yet satisfactory. Data are not flowing from (1) The Bank should strive to step away from the regions to the central region. In part this is the the lead role in program design to encour- result of a "greve du Zele", where health staff in the age complementarity among donors and to regions strike by withholding data. This has required promote ownership. ad hoc studies to gather data on program perfor- (2) Set the parameters of the design process at mance in the regions. Other implementation prob- an early stage in terms of who is in charge, lems have resulted from difficulties on the part of the role of each agency, how donor collabo- central MOH authorities to delegate functions to ration will be achieved, and participation regional offices. The decentralization has been agreed by stakeholders. to in principle, but effective mechanisms to manage (3) Confirm that the five criteria or precondi- the relationship between elected bodies and the tions mentioned above are met, or likely to deconcentrated sectoral entities have not yet become be met in the early stages of program de- fully operational. Sometimes this is being resisted velopment before starting on the process. 79 ANNEX 4: SENEGAL HEALTH CASE STUDY (4) Basket funding, or pooling of resources, is procedures that could be used by all parties not necessary at first. A "transition SWAP" at a later stage. can be designed that allows donors to (5) It is important for the Bank to show some contribute funds in accordance with their flexibility in order to play its role as donor own procedures that can be accounted for of last resort and to cover any financing gaps separately, while working on a common that might emerge during program imple- objective of strengthening government mentation. 80 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA TABLE 1 2369 - Senegal Integr. Health S. Dev. Project Status Report Date: 6/22/99 Region: AFR Country: SENEGAL Sector: HH Lending Instr: SIL Prg Obj Cat: PA EA Cat: C PTI? Y NGO? Y Resettlement? N LOAN INFORMATION Agree LICIG Rev'd Currency Prod Signing Effective Suppi Prj Type No. OrigAmt Amt Indicator Line Date Date ID IDA 29850 35.90 (SDR) PE 9/15/97 2/2/98 Total Original Amount (SDR): 35.90 Total Revised Amount (SDR): 0.00 COPINANCING INFORMATION Agency BoardAAmount($M) CurrentAmount($M) AFDB 10.00 10.00 BEL 2.00 2.00 EU-EC 14.00 14.00 FAC 1.00 0.00 FPPI 4.00 4.00 FRA 1.00 GTZ 3.00 3.00 ISLAMIC 5.00 5.00 ITA 3.00 3.00 KFW 3.00 3.00 NDF 5.00 5.00 NET 4.00 4.00 UNICEF 5.00 5.00 Total 59.00 59.00 Guarantee Type: Guarantee Amount ($M): This form is part ofh Supervision Mission Read together with: Aide-memoire Mission End Date: 6/4/99 This Form PSR Date: 6/22/99 BTO memo of: Months since last mission: 8 Last Form PSR Date: 12/14/98 Follow-up letter of: 6/4/99 Next mission planned: 10/18/99 Total Field SUPERVISION Staff- Total Staff- Fied As of EFFORT Weeks $000 Weeks $000 6/22/99 Current PY - Planned 27.50 70.85 Current FY - Actual 37.38 87.78 0.00 0.00 Board through preceding FY 21.10 65.85 0.00 0.00 Total Actual 58.48 153.63 0.00 0.00 No. of Role or Previous UPI No. Mission Member Division Fld Days Specialization Mission 185252 SY AFMSN 20.0 HNP OPERATION SPEC. Y 95309 THEUNYNCK AFTH2 2.0 IMPL. SPEC Y 185252 SY AFTH2 20.0 HNP CLUSTER LEADER Y 81 ANNEX 5 Zambia Health Case Study' Health Sector Support Project (HSSP) BACKGROUND was a key area of concern in Zambia's adjustment program and development strategy. Government Since independence the Government had used its commitment to improving health services had been international borrowing capacity to support levels evidenced by increased allocations to health (from of consumption in the public sector that proved 6% of the budget to 13% in 1994/5/6). Its commit- unproductive and unsustainable as its wealth- ment to reform was manifested in the 1991 National dependent on copper prices-declined. At the time Health Policy paper which outlined the government's of initial project design, Zambia suffered from ex- aims for reforming the health sector in order to pro- cessive public sector dominance, a decline of nearly vide Zambians with "equity of access to cost-effec- 50% in per capita income since 1975, and a dramatic tive quality health care as close to the family as increase in poverty. Funding cuts in all social sec- possible." tors during the economic crisis of the 1980s had led to several dilapidation of health infrastructure. The health sector was overwhelmed as population growth, SECrOR PROGRAM DESIGN combined with increasing incidences of diseases, such as AIDS and malaria, raised demands for basic health Lending Instrument: The project is supported by a care. Infant mortality rates rose, the prevalence of Sector Investment and Maintenance Loan (SIM). malnutrition increased, and vaccination rates for In fact, it is a Sector Investment Program (SIP), one children fell. Access to health facilities, the quality of the first to have been financed in the social sec- of services, and the availability of drugs and sup- tor in Africa. The government took the lead in pre- plies varied widely. Health staff were concentrated paring a common framework under which donors in urban hospitals (80 percent of all physicians) while to the sector, including IDA, could provide sup- health facilities in rural areas with 60% of the popu- port. The main components of the SIP approach lation remained understaffed. were: The commitment to change was established in November 1991 when a new government was elected > The development of a single, comprehen- on a platform of adjustment and policy reform. The sive strategic framework that could be rehabilitation and reform of social service delivery agreed on by all "Cooperating Partners". 'Based on interviews with Ms. Julie McLaughlin, former Task Team Leader, and the sources listed in the bibliography at the end of the case. 83 ANNEX 5: ZAMBIA HEALTH CASE STUDY > An annual implementation plan and annual this was the precondition that led to the develop- comprehensive budget for the investment ment of the sector program. Other considerations and operating costs of the sector. Donors were secondary. were asked to structure their support to Definition of the sector: The sector includes all meet those financing needs that could not things for which the Ministry of Health is respon- be met by government - primarily invest- sible. The definition is thus comprehensive,2 includ- ment costs. ing central, district and local levels - as well as all > Joint implementation procedures - account- programs undertaken by the Ministry. There were ing, disbursement, reporting, monitoring, no other agencies of government explicitly respon- and evaluation. sible for health. Program leadership: The impetus for reforms Rationalefor the sectorprogram: One of the rea- came clearly from the government. Zambian offi- sons a sector program was undertaken was the cials clearly were driving the health sector reforms government's comprehensive vision of the sector. and program development. In the run-up to the first This included innovative approaches including a shift national election in 1991, the eventual party that won toward primary from tertiary care and decentrali- prepared a manifesto on health reform. The person zation to districts. A second reason is that the Bank who wrote the party manifesto on health became wanted to support donor-initiated reforms. As stated the Deputy Minister of Health. Shortly thereafter the in the SAR, "There is no practical alternatives to the government approached the Bank informally about proposed sector approach, as a traditional invest- support for the program. The Bank found the pro- ment project would destroy the Government-led gram innovative and wanted to respond in an inno- process of reforms..." (SAR, p. 30). Third, although vative manner. There was no model for supporting the Bank had no previous projects and direct expe- a sector-wide program. The program design was de- rience with lending for health in Zambia, experience veloped almost exclusively by the government (spe- in other countries demonstrated the need for more cifically the Deputy Minister of Health and the chief comprehensive and integrated involvement in the health planner), with donor involvement increasingly health sector to ensure sustainable development only later in the process. As the Task Team Leader impact (SAR, p. 32). One reason was that projects said, "IDA jumped on a moving train." typically have gaps in financing that leave critical Donor coordination: The government took the inputs underfinanced. Another reason was the "re- initiative to get donors interested in the program. placement mentality" where project funds allow Initially IDA, the WHO, and UNICEF were the agen- government funds to be used for other, less priority, cies most interested. DANIDA was the first bilateral purposes, i.e., "fungability." participating in preparation, followed by the Swedes, Preconditions: Macroeconomic stability was Dutch, and British. IDA instigated donor coordina- cited later as a condition for starting a sector-wide tion, but it was performed by the government. The approach in Zambia, but those developing the government called and hosted all the donor meet- project focused on sector-specific issues dealing with ings and missions. reform. The impetus of the reform was the govern- Program development: The first step in program ment commitment and efforts to reform the health development was taken by Zambian officials in the system along lines endorsed by the Bank. In effect, preparation of the National Health Policy paper in 2 Later, there was a mistaken impression in some quarters that the sector program was not in fact sector-wide and dealt only with districts (perhaps because pooled financing was limited to district grants). 84 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA 1991 based on the party manifest. The second step comprehensive health sector strategy, the budget was the preparation of the Strategic Plan during envelope, decentralization, and the government's 1992-93 with Bank assistance. The adoption of a commitment to delivering an essential package of sector-wide approach compelled the Bank to become care. During the appraisal, several interest groups involved in the national planning of comprehen- lobbied to increase the list of deliverables and the sive health care reform rather than focusing on pieces Zambian officials realized they would be in trouble of the reform process, the traditional project ap- if they tried to please everyone. This led to the adop- proach. As an integral part of this work a Bank mis- tion and use of cost-effectiveness analysis to deter- sion introduced a health planning framework to the mine what services to deliver. The appraisal focused Ministry of Health in May 1993. The tangible out- on processes-the structural, legal, organization, and put that was catalyzed by this planning process was management of the delivery of a package of health the Strategic Plan for health reform, which details services, rather than on traditional "programs', such plans for how the new health system will operate, as immunization or AIDS. In the sector support what inputs it requires, and how the Ministry in- model for financing, project preparation and ap- tends to transform the existing system into the new praisal were focused on the nature of the apex one envisaged. In preparing the Strategic Plan the institution's involvement and the processes by which Ministry of Health formed committees around each specific investment items would be identified dur- component of the reforms. They: (1) undertook a ing implementation. In the end there was a lot of critical assessment of health needs, identifying fi- trial and error. The government minister supported nancial, physical, human, and academic resources the trial of different elements and allowed failure. and considering the stakeholders in the process; (2) Level of sector analysis: The Bank had in its pos- defined a new set of health system standards-on session several earlier studies on sectoral issues from the basis of equity and affordability principles- the late 1980s from the development of a health through packaging cost-effective health care; (3) project that had never materialized. (In fact, a health identified requisite inputs and management support mission was in the field working on the project when by level of institution and its anticipated workload; the Bank abruptly stopped its operations in Zambia (4) estimated consequent costs by types of expen- and withdrew representation.) However, these were diture; (5) identified a health financing strategy to somewhat dated, and were not relevant to the com- cover these costs, including ministry budget, pri- prehensive program. Some new studies were done vate expenditures, and external donor support; and on specific topics in preparation of the Strategic Plan, (6) committed the government to monitoring the but much needed sector analysis was done after progress of implementation and the impact of re- Credit commitment. For example, the expenditure form on target beneficiaries (SAR, pp. 6-7). The Bank review was done after effectiveness. After effective- subsequently assisted the development of policies ness, analytical work was done on human resource regarding the financing of a minimum package of issues and "burden of disease" issues, and work con- cost-effective health services, and determining how tinued on the definition of an effective minimum private financing might increase resources available package of goods and services. In effect, the initial to finance essential services. However, the Bank had policies and plans-while generally found to be ac- little influence on the basic policy decisions (decen- ceptable through appraisal-had been prepared tralization, charging user fees, delinking health staff without sufficient analytical background. The spe- from the civil service) as these decisions were rooted cific gaps were then filled during implementation. in the earlier Health Policy. The third step was ap- In effect, the Bank went to the Board in the midst of praisal in 1994 jointly by all interested donors. The preparation without all the details. Since it was a government made a series of presentations about process, it was felt that completion of preparation the program to donors. The mission appraised the did not matter so much as donor commitment to 85 ANNEX 5: ZAMBIA HEALTH CASE STUDY the reform process and the agreed framework and opment, and recurrent) based on annual agree- objectives. ments. The exact mix of financing would be deter- Institutional capacity: Institutional capacity was mined on an annual basis, but with a three-year not analyzed rigorously in advance, and in retrospect rolling program. may have been one of the weaker elements of pro- The Credit was divided into three major com- gram preparation. DANIDA was working on finan- ponents, including (a) support for operations re- cial management and information systems and the search and policy development (an estimated 3% of Bank relied on that work. Even the Program Coor- Credit proceeds); (b) investment program support dinator had to be trained on the job. The project (95%) and incremental recurrent budget support launch was not particularly well thought through. (1%); and (c) external monitoring and evaluation In a way, the enthusiasm and commitment of Zam- (1%), including beneficiary assessments and audit- bian officials for the reform program compensated ing. The overall investment program was to be a for the initial lack of capacity to manage the pro- consolidation of investment programs prepared by gram. The program was fortunate to have compe- individual districts, hospital boards, and the central tent people involved and things went well initially MOH. It included three elements: (i) infrastructure for three years because of this. and equipment, including "transparent criteria and Stakeholder consultation: Stakeholder consulta- standards ... in the Strategic Plan to enable the Health tion was done effectively. Many consultative meet- Boards to qualify for supplementary assistance and ings were held with district staff. The scope of supervision" (SAR, p. 20); (ii) capacity building to consultation was relatively narrow initially, mainly improve planning and implementation skills at the focused on district public health providers. Gradu- various levels in the areas of clinical competence, cor- ally the "net" widened, in part with the encourage- porate planning and management, monitoring and ment of donors, to include hospital boards, private supervision; and (iii) supplies to ensure a regular health providers, the few local NGOs that existed, supply of essential drugs and materials for the health and parastatal organizations (pharmaceutical com- service to function effectively. pany,mines).Adeliberatedecisionwasmadetoleave Modus operandi: A detailed determination of out central program managers (e.g., TB, AIDS, nu- components to be financed would be the outcome trition) from the initial consultation process because of a district planning process, a consolidation of the reform was attempting to overcome the vertical individual plans prepared by districts and hospital "empires" such programs entailed. This was later re- boards. Thus, a"bottom-up" planning process is one gretted and rectified. of the key methods for the implementation of the program. These were not investment plans, but op- erational plans for non-personnel non-pharmaceu- THE PROGRAM tical recurrent costs, e.g., plans to increase immunization through improving the cold chain. Objectives, strategy, and content: The IDA project Training seminars were provided for district staff supports the government's health reform program in how to prepare plans. The center gave guidelines with a view to improving access to, and the quality to the districts and seven referral hospital boards of, a national package of essential health services for how grant funds could be spent, such as limits in a decentralized health care delivery system. on spending for certain items - for example, no more This reform program was explained in the Strate- than a certain percentage on repairs, allowances, or gic Plan and was agreed on with a core group of fuel. The plans included the submission of a set of donors. IDA financing fits with the national health targets. If the plans were accepted, the district would reform program, financing a slice of each of the receive a per capita allocation weighted in favor of three national budgets (investment, policy devel- poverty and rural areas. The criteria for evaluating 86 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA the plans included consistency with national goals bulk of oversight and management, but the MOH and the adequacy of specific programs proposed. retained authority over implementation. Guidelines evolved and were developed further each The development of common implementation year. They reflected emerging priorities and desired procedures has received attention. DANIDA financed directions and strategies. work aimed at developing joint government/donor In traditional investment projects, the prepa- accounting, reporting, and disbursement systems. ration and appraisal process focus on reviewing and The aim was to reduce demands for individual do- planning the specific items (such as infrastructure nor financial reports and facilitate an evolution to- or support systems) slated for financing. In this case, ward a single "basket" account for the financing of the project supports the government in ongoing the health sector. In an effort to better institutional- development of policy and its operationalization, ize monitoring and evaluation activities and reduce even as reforms are proceeding. Therefore specific the demand on ministry program staff, a system of items are being identified throughout the imple- quarterly and annual joint reviews helps incorpo- mentation of the project. The mechanism for iden- rate reporting and review requirements for all Co- tifying priorities and agreeing on budgets is the operating Partners, and aims to supersede eventually semiannual review. These reviews alternately assess the previous pattern of specific reviews by individual progress in meeting previous agreements (April) donors. and plans for the coming year (October). The April Financing The total program cost was estimated review covered the implementation of the entire at $537 million from 1995 to 1998. The Government health reform program as detailed in the Strategic was to finance $340 million (63%), IDA $56 million Plan, not simplythe components supported through (10%), and other donors3 $141 million (26%). No donor, or IDA financing, and includes assessments allowance was made for contingencies. "The num- of both finances and programs. The October re- ber a size of activities would be revised to fit within view considered the annual update of the Strategic the existing financing framework" (SAR, p. 34). A Plan as prepared by the Ministry of Health. It in- detailed determination of the investment items could cludes a rough, rolling two-year investment pro- not be made up front as this depended on the out- gram, an annual recurrent cost budget, and come of the district planning process, i.e., bottom- identification of areas for which donor support is up planning, and annual agreement on the sought. At the same time, the Ministry presents an investment plan and recurrent budget. It was agreed annual implementation plan with investment and that IDA would remain the "lender of last resort" by recurrent cost budgets. Donor commitments are supporting those elements of an agreed-upon pro- sought for the next year. Each donor then bilater- gram for which no other donor funding could be ally structures its support on the basis of the docu- identified. Some $6.3 million (11.3%) of the Credit ments and agreements. proceeds were unallocated. The Planning and Management Unit (PMU) of Risks and dangers: Abandonment of the health the Ministry of Health, an existing unit that coordi- reforms was explicitly recognized in the appraisal nates all donor-financed investment in the sector, report as a clear project risk, but it was felt that the was initially responsible for program oversight and risk had been minimized by adjustment credits. An- management (all MOH-implemented). Subse- other risk would be "internal political change." How- quently, as the Central Board of Health (CBOH) was ever, the SAR states: "Such change has already been formed, the CBOH assumed responsibility for the weathered during the project preparation process. 'ODA, SIDA, DANIDA, The Netherlands, UNICEF. 87 ANNEX 5: ZAMBIA HEALTH CASE STUDY The broad-based support and momentum for health SECTOR PROGRAM IMPLEMENTATION reforms, both within the MOH and in districts across the country, would make it difficult for a different Implementation experience: government or a different minister to annul what is already in the pipeline" (SAR, p. 41). Reference was (1) The reviews of past performance in April also made to a risk that implementation of the Stra- were typically less successful than the con- tegic Plan would be stalled on "process issues" with- sultative prospective meetings in October/ out making impact on services and beneficiaries. It November. One reason is that the progress was assumed that lack of progress in making progress reports prepared by the government were would be addressed in an acceptable manner within not particularly good, although they were the annual review and planning process and the next comprehensive, and monitoring and evalu- year's plan of action (SAR, p. 42). A final risk noted ation capacity was weak. The prospective was that donors may not agree to use common pro- consultative meetings, by contrast, were held cedures and some would continue to provide aid with outside Lusaka and involved headquarters conditions that were not compatible with the agreed staff plus consultants from the various do- Strategic Plan. Continued dialogue among the do- nor agencies. These meetings dealt in depth nors and government, it was assumed, would mini- with issues concerning pharmaceuticals, re- mize this risk. productive health, financial framework, dis- Conditions: The IDA Credit came with relatively trict capacity building, and standards for few conditions. A condition of effectiveness was the infrastructure. Concurrent working groups full financing of the investment program and bud- on the issues often were the same from year get for 1995. Conditions of disbursement were (i) to year. The results of these deliberations acceptable standard architectural designs for district often effected modifications in the Strate- level facilities, and (ii) disbursement of $10 million gic Plan, or the joint donor/government on district facilities before any disbursement on cen- statements. tral and regional facilities. The other conditions speci- (2) The annual meeting was effective, inter alia, fied that implementation would follow the Strategic because (a) it gave external agencies an op- Plan, investment program and budget, annual sub- portunity to be involved and an opportu- mission of a progress report on Program implemen- nity to influence sector plans, and (b) it tation, and annual submission of a revised Strategic provided openness between government Plan, budget, investment program, work, training, and donors. Other countries sent represen- and procurement plans (SAR, p. 43). The main se- tatives to the annual meetings to observe the curity for IDA and other donors was in the annual dialogue and deliberations. These represen- review process at which time problems could be tatives remarked on the openness of the addressed and presumably solved. There were no dialogue, even on contentious issues. special remedies included for poor performance. In (3) The Zambia program pioneered the use of the worst possible case the legal agreements fell back "basket funding'" or pooling of donor con- on the standard remedies: suspension and cancella- tributions into a common account. The idea tion. As stated in the appraisal report, "If it should of financing against the government bud- prove to be impossible to recommend a continua- get started with the proposed DANIDA tion of the sector-wide approach, as reflected in dis- grant funds to districts. Although this idea agreements between IDA and the Government on did not materialize during the design stage, the Strategic Plan, the investment program or the donors supported the concept during imple- health budget, implementation would be halted and mentation. Donor funds were pooled for ultimately the credit would be cancelled" (SAR, p.30). district grants and made use of common 88 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA accounting and reporting procedures devel- dialogue in the 1998 annual meeting. Imple- oped with DANIDA assistance. Separate mentation of the program came to a stand- donor accounts were established at the cen- still. DANIDA suspended most of its ter. They were released monthly and were program. Few funds have been disbursed commingled at the district level, i.e., donor from the credit in over one year. Several origins could not be identified. The release procurement applications have been re- of funds by the center was negotiated with jected by the Bank. all donors. Each donor had veto power. (6) A Memorandum of Understanding was (4) In practice, the Bank as a "donor of last re- worked out among the donors, but was not sort" did not work particularly well because signed because of the ensuing issues that de- detailed budgets were never sufficiently de- veloped in the subverting of the reforms. veloped against which expenditures could (7) During implementation the Task Team be justified. The Special Account (SA) be- Leader remained in Bank headquarters. The came a slush fund. Whenever money was question arises whether problems would not available, the client went to the SA for have been avoided by staff representation funding, including staff allowances and in the Resident Mission. On balance, this housing for staff. reportedly was not a hindrance. It made for (5) During program development and imple- about five missions per year, but perhaps mentation there have been four different also afforded the opportunity for the Bank ministers of health. The second minister to have a different perspective from other tried to derail the reforms, but parliamen- donor representatives who followed events tarians supported the health manifesto and daily from within the country. brought him back into line. Broad approval (8) So far only one-third of the Credit proceeds was required to delink the health staff from have been disbursed after five years of imple- the civil service (including defeating law- mentation. The main reasons for the low suits), create the Central Board of Health, disbursements were disagreements just be- and make districts into autonomous boards. fore bulky disbursements on large contracts. Thus, the reform had broad-based and high level support. Prior experiences with changes of leadership had not altered the OUTCOMES SO FAR directions of reform. However, all that changed in 1998. In 1998 a new minister of Main achievements: Most of the progress achieved health was appointed. The new minister under the program was made in the first two years of changed, not officially but in effect, priori- approval of the IDA Credit. The areas of achievement ties and placed emphasis on support for ter- were defined and actions were taken that had to be tiary care institutions and centralization. further developed, reinforced, and sustained in the This had the effect of reversing some re- remainder of the program implementation period. form strategies. The criticism was leveled that the reforms had not resulted in better (1) There has been a dramatic increase in the service to beneficiaries. In addition, some capacity of districts to plan and manage their serious issues arose about corruption in the affairs. pharmaceuticals stores. The new minister (2) In terms of reorganization and restructur- took an adversarial relationship with do- ing, the Central Board of Health was cre- nors. The openness that had prevailed ated as were autonomous hospitals and evaporated. The minister prevented an open district boards. 89 ANNEX 5: ZAMBIA HEALTH CASE STUDY (3) Health staff were started to be delinked from (2) Pharmaceutical reform. This item was not the civil service (this has now been halted). on the agenda at the beginning of the re- (4) An essential package of care has been de- form program. The government did not fined. want to discuss it. The first minister and the (5) The budget allocated to tertiary care has de- permanent secretary of health were fired creased in favor of budgets for the districts. over a drug scandal. This was a thorny is- (6) In terms of actual impact the story is more sue because of the patterns of corruption mixed. Immunization coverage did increase involved in pharmaceuticals. (Astonishingly, and the demographic and health survey the parastatal agency for drugs is now man- showed some improvements in terms of aged by an international arms dealing firm). increased access to reproductive health and increased satisfaction with health services (in terms of cleaner facilities and more pleas- OBSERVATIONS AND POSSIBLE LESSONS ant staff). (1) The preparation process for the SIP took two Main problems (or lack of achievements): years more than a traditional project would have taken. In part, this is because the Min- (1) Spending versus budget. The program has istry of Health has taken the lead in shap- suffered from inappropriate spending ing the implementation of health reforms. within the health budget. The allocation to Ensuring that the Ministry remained the the social sectors has been maintained, in primary decision-maker often entailed mov- part through conditions imposed under ing at a slower pace than the project prepa- adjustment credits. The Ministry of Health ration team anticipated. The local sense of was getting the budget funds, but the funds ownership and spirit of collaboration helped were not getting distributed to intended achievements in the early years of project beneficiaries. Pharmaceuticals were not fi- execution. nanced (this was a major dispute in 1998). (2) In hindsight, four years after the start of Care abroad (mainly for AIDS patients in project implementation, it is clear that the South Africa) was amply financed, but dis- directions for development of the sector were trict grants were underdisbursed (in 1998 not fully explicit. There were no objectively only 60% of the budget was allocated). The verifiable indicators that could define ad- causes for underspending in important cat- herence or deviation from the agreed plan. egories was partly the result of inexperience Too much was left to interpretation and with budgeting processes and underantici- opinion. The Bank did not agree with the pation of needs. Another cause was lack of Government and other donor partners on financial information. A third reason was outcome indicators, indicative targets, and overoptimism in ability to reallocate re- milestones for jointly monitoring the pro- sources. The hospitals from which resources gram. In retrospect, useful indicators would would be transferred to districts existed and have been spending as a percentage of bud- could not be allowed to go bankrupt; they gets on primary, secondary, and tertiary fa- had to be sustained through the budget. The cilities; and availability of drugs. There autonomous hospitals consumed 70% of the should have been specific, clearly stated mile- recurrent budget. Capacity building did not stones, e.g., CBOH established with an ac- include strengthening the financial manage- ceptable memorandum of understanding ment of these entities. between CBOH and the MOH; legislation 90 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA supporting decentralization passed, etc. It regarded by the client as interference and is therefore advisable first to get baseline data therefore cause resentment. and agree on indicators and not to make (9) One issue to be faced in a sector program is commitments until there is explicit agree- this: how do specific needs get covered when ment on what constitutes progress. the attention is given to the overall program? (3) Thought should be given before commit- For example, in health, how does one en- ments on how to resolve disputes - among sure that child health, AIDS, maternal health, the donors and between donors and the cli- and nutrition will get sufficient attention in ent. Does majority rule? Or is it weighted the overall program? One method is to as- by how much each donor is contributing? sign specific programs to particular donors (4) Lack of linkages between performance and and ensure that all programs are adequately disbursements. Funds were not disbursed covered. For IDA the dilemma is that it is against performance and targets. perceived as not doing what it does not di- (5) Remedies: The legal language was not strong rectly finance. enough on agreement on the investment (10) The criticism of sector programs is that they program. Funds were not released to dis- focus more on process than on substance, tricts and more funds were spent than impact, and outcomes. However, this mis- planned on central MOH, CBOH and phar- represents the issue. Process supports the maceuticals. The Bank did not have anything changes required to achieve impact. The in the legal documents to deal with a situa- "production model" needs to be clearer in tion in which distortions occurred in the the health reforms. program. There were no remedies short of (11) IDA involvement extends throughout the suspension and cancellation. These are ex- sector. Rather than only focusing on ma- treme measures that leave IDA isolated and laria, childhood diseases, the training of without the means to continue the dialogue. health cadres, facility renovation, drug se- The recommendation is: do not lend with- lections, cost-recovery policies, or other out recourse. Think of remedies from the "project" components, the Bank team is first day of project development. forced to be aware continually of any issues (6) A standard is needed to ensure that the that might obstruct progress for the sector Bank's role as donor of last resort works as a whole rather than the component properly. The use of the Special Account be- being financed by the IDA Credit. This is came distorted in this case. A proper, com- more time-consuming and demands a prehensive, and operable budget could have greater familiarity with health sector issues served as this standard, and should have than might otherwise be required. In a sec- been possible, but-as presented to the an- tor-wide approach considerable effort is nual consultative meeting-was lacking in needed to analyze the system and keep the detail. knowledge of donors up to date. This re- (7) The Zambia experiences show clearly how quires continuing analysis, and reanalysis, the SIP depended heavily on dialogue, which such as expenditure reviews. It is costly. It then broke down. There is no alternative if cannot always be included in the loans/cred- the dialogue breaks down. its (it's not in the Government's interest (8) The case also shows the sensitivity of deal- sometimes to have these review of problems ing with policy issues and the full sector and progress). Supervision of a sector pro- program. This gets donors deeply involved gram takes at least 50% more budget than in all aspects of the sector, which may be normal. 91 ANNEX 5: ZAMBIA HEALTH CASE STUDY (12) The extent to which this approach depends rapid measurable outcomes. Some consid- upon effective donor coordination cannot eration is now required as to how the Bank be underestimated. Donors and government should measure success in such an inte- must remain in regular contact in order to grated sector project. recognize and respond to needs throughout the sector, for example, stepping in when critical sources of financing are delayed, or BIBLIOGRAPHY mobilizing a common response to policy decisions that might have an impact on the Joint Donor and Ministry of Health Statements. 1994, health sector. The interdependency inherent 1995, 1996, 1997. to the integrated sector approach has engen- Mahler, Halfdan, et al. 1997. "Comprehensive Re- dered and necessitated mutual trust and view of the Zambian Health Reforms." Report transparency. It also demands responsive- of an independent review in September 1996. ness, flexibility, and continuity on the part May 1997. of Bank staff. McLaughlin, Julie. 1997. "What Can We Learn from (13) Because inputs to the sector are better co- Implementation of a Sector-Wide Investment ordinated and because the government is Approach to Lending?" Presentation at HNP encouraged to lead the process, the ap- Training Day for HD Resident Mission Staff. 19 proach is expected to ensure better impact March. on health status and achieve more sustain- . 1998. "Supervision Report: Zambia Health able results. At the same time, it may mean Mission" April 2. that measurable outcomes are less readily Republic of Zambia Ministry of Health. 1998. obtained. It may be a trade-off between "Memorandum of Understanding Between the achieving short-term but unsustainable Ministry of Health and Cooperating Partners in aims versus impact over a longer term that the Health Sector." July. is sustainable. Reductions in morbidity/ World Bank. No date. "Turning the Tables for mortality of a specific disease could be more Zambia's Health System." Handout in the "In- easily achieved under a disease-focused vesting in People" and "The World Bank in Ac- project, or progress in health personnel tion." Human Development Department. achieved if the project focused on training. World Bank. 1994. "Staff Appraisal Report, Zambia: It is more laborious to push the entire sec- Health Sector Support Project." Human Re- tor forward than to limit the scope to dis- sources Division, Southern Africa Department, crete projects that would produce more Report No. 13480-ZA. October 14, 1999. 92 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA TABLE 1 3239 - Zambia, Health Sector Project Status Report Date:.6/30/99 Region: AFR Country: SENEGAL Sector. HH Lending Instr: SIL Prg Obj Cat: PA EA Cat: C PTI? Y NGO? Y Resettlemeent? N LOAN INFORMATION Agree L/C/G RevW Currency Prod Signing Effective Suppi Pj Type No. OrigAmt Amt Indicator Line Date Date ID IDA 26600 38.70 (SDR) PE 12/8/94 2/24/95 Total Original Amount (SDR): 38.70 Total Revised Amount (SDR): 0.00 COFINANCING INFORMATION Agency Board Amount ($M) Current Amount ($M) DANIDA 20.00 20.00 DIGIS 60.80 0.00 NET 0.00 60.80 ODA 24.90 24.90 SIDA 21.20 21.20 UNICEF 14.00 14.00 Total 140.90 140.90 Guarantee Type: Guarantee Amount ($M)- This form is part of. Supervision Mission Read together with: Aide-memoire Mission End Date- 5/25/99 This Form PSR Date: 6/30/99 BTO memo of: Months since last mission: 6 Last Form PSR Date: 1/26/98 Follow-up letter of: 6/15/99 Next mission planmed: 11/1/99 Total Field SUPERVISION Staff- Total Staff- Field As of EFFORT Weeks $000 Weeks $000 6/22/99 Current FY - Planned 30.50 110.59 Current FY - Actual 26.63 92.25 0.00 0.00 Board through preceding FY 236.05 664.70 50.15 152.73 Total Actual 262.68 756.95 50.15 152.73 No. of Role or Previous UPI No. Mission Member Division Fid Days Specialization Mission 705 BERK AFTH4 8.0 MISSION LEADER Y 98421 FOLLMER AFTH1 7.0 OPERATIONS N 112460 KRISHNAKUMAR AFTS1 5.0 PROCUREMENT Y 175455 SIAMATOWE AFMZM 10.0 SOCIAL SECTORS Y 194952 MUMBA 10.0 PROCUREMENT N 175456 MUSUNGWA AFMZM 10.0 FINANCIAL MGMT N 93 ANNEX 6 Ethiopia Education Case Study' Education Sector Development Program (EDSP) BACKGROUND in the first year. Physical facilities are in disrepair because of war damage and absence of preventive Ethiopia has the second largest population in Sub- maintenance. Finally, the sector is seriously Saharan Africa, but a per capita income of only about underfinanced. $110, one-fourth the average of the region. Nearly To address the above issues the Government three decades of civil war and mismanagement prepared a new Education and Training Policy and through a centrally planned economy reduced the Strategy in 1994, which focused on restructuring, average per capita income in 1991 below that attained expanding, and improving the quality of the educa- in 1960. The economy, however, embarked on rapid tion system. This led to the creation of a 20-year Edu- recovery and growth once the civil strife ended in cation Master Plan and an Education Sector 1991. Economic stabilization and reform programs Development Program (EDSP) covering the first five contributed to an annual GDP growth of 5-8 per- years of the long-term program. Donors were in- cent in the first half of the 1990s. vited to participate in the final development and fi- As a result of previous neglect, Ethiopia's edu- nancing of the ESDP in late 1996. The Program was cation sector is characterized at all levels by extremely launched by the Government in 1997/8. low overall participation rates (30% at primary, 13% at secondary and less than 1% at tertiary levels). Its gross primary enrollment rate of 30 percent is one SECTOR PROGRAM DESIGN of the lowest in the world and less than half the av- erage for Sub-Saharan Africa. Girls' participation Basic data: The EDSP is classified as a Sector Invest- rates are much lower than those of boys, especially ment and Maintenance (SIM) in terms of the Bank's in rural areas. In addition, there are severe urban- instruments. That is, it (a) is sector-wide in scope; rural and regional differences in access to education (b) is based on an agreed program with all major (ranging from 7% in the Afar region to 87% inAddis donors; (c) contains a comprehensive expenditure Ababa). The quality of education is poor with inad- plan in which the donors will finance a part; (d) is equately trained and poorly motivated teachers and client-led; (e) incorporates efforts at using the and lack of instructional materials. The system is ineffi- strengthening the client's procedures; and (f) includes cient and one-third of students drop out of school harmonizing procedures; among the donors. The lBased on two interviews with Mr. Arvil Van Adams, The Project Appraisal Document dated May 4, 1998, the Bank's "Quality at Entry Assessment" for CY 1998, and Martin, Oksanen, and Takala, "Preparation of the Education Sector Develop- ment Programme in Ethiopia," June 7, 1999. 95 ANNEX 6: ETHIOPIA EDUCATION CASE STUDY Quality at Entry Assessment (QEA) states that "an was an adequate knowledge base for a sector-wide APL would have been a preferable instrument. An program, in part generated through an Ethiopian- APL would have forced the government, donors and executed PHRD grant. the Bank to confront important issues of sequenc- Definition of the sector: ESDP is a sector-wide ing that are now dangerously implicit. It would have program that encompasses all education-related exerted some discipline on the donors. However, the undertakings of the Government, both at the cen- Government refused to use an APL. The project now tral and regional levels. (Program Appraisal Docu- has implicit annual tranches, but no explicit trig- ment [PAD], 14) The education "sector" covered by gers" (Section 1.5). the ESDP is therefore comprehensive, including all It took ten months for preparation of the ESDP, levels and types of education. Specifically, the Pro- and from the March 1997 presentation of ESDP the gram includes basic education, secondary education, program was delivered in just over one year, in May technical and vocational education and training, 1998. (See data sheet). teacher training, tertiary education (both formal and Rationalefor the sectorprogram: From the Gov- non-formal), special needs education, distance edu- ernment perspective, the problems in education were cation, and institutional development. However, as massive. Isolated projects were felt to provide an reported in the QAE report, there is only a modest inadequate strategy for improving the situation. focus on secondary education, only a "studies posi- Specific projects in the past had tended to have lim- tion" on vocational training and little on tertiary itedimpact (Martin, Oksanen,andTakala,p. 6). From education (section 1.4). All of the subsectors are the donor perspective, the sector program is a re- within the purview of a single Ministry, the Minis- sponse to a Government-initiated sector program. try of Education. The unified management structure One reason was therefore to support the Govern- was a factor contributing to the success of program ment-led initiatives. Another reason was the search development (compared with, say, Zambia education, for a more effective approach to external assistance. which involved four ministries). IDA, for example, had seven previous projects in the Program leadership: A distinguishing character- education sector and had relatively few accomplish- istic is the strong leadership asserted by the Gov- ments to show for it. Specific investment credits ernment. There was little donor involvement in the would continue to have limited impact, but a sec- initial phase of the development of national policy tor-wide approach was more likely to identify, ad- and strategy. After the overall program was devel- dress, and have success in solving the most critical oped the Government invited donors to participate issues for education as a whole. In addition, the sec- in financing it. This led to intensive collaboration tor-wide approach could avoid the "balkanization" between the Government and donors in detailed or fragmentation of donor aid to the education sec- preparation of the program. In all aspects the Gov- tor. Moreover, harmonization of procedures could ernment was in the "driver's seat" for the program. help ease the burden on Government of different Another characteristic was the continuity of staff on procedures and PIUs insisted on by different donors. the central government side (although not in all the Preconditions: First, the government had regions involved). achieved a growth environment in the 1990s. It had Donor coordination: The Government and other the right macroeconomic policies, and GDP was donors asked the Bank to lead the preparation of growing an average of 7% annually, generating re- donor assistance to the Program and the missions sources to support additional investment in the so- to prepare the details of the program. Apart from cial sectors. Second, the Government had developed formal meetings, the Task Team Leader spent enor- a credible sector program without donor interven- mous amounts of time with donors to ensure coor- tion. Substantial Government ownership and com- dination of efforts. The need to collaborate with other mitment backed up the policy document. Third, there donors takes some of the control out of the Bank's 96 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA hands. For example, during program preparation a (2) 1995: Education Sector Investment Program mission had to be delayed at the request of the EU prepared by Ethiopian consultant because it could not field its team on time. The num- (3) December 1996: Submission of ESDP to ber of donors participating in ESDP preparation grew Consultative Group meeting inAddisAbaba. from 11 in the first mission to 15 by the final mis- The government was somewhat resentful sion. A wide range of specialists were involved in the that donors wanted to question the program three preparation missions, and the number of each and carry on a dialogue about its content. mission ranged from 19 on the first to 30 specialists After the meeting background papers were on the third mission (Martin, et al., p. 7). One prob- distributed to the donors for review in lem was that the technical specialists, often consult- depth. ants, were not authorized to speak for the donor (4) March 1997: "Debre Zeit I" covering both agency. This made it difficult to get official agency education and health: Government-led views on issues during the missions. One review of workshop on social sector investment pro- ESDP found that there was a "lack of forum for dia- grams. The purpose was to get feedback logue on policy and strategy development and man- from donors about the program and indica- agement issues", and "by default, the team leader of tive budget support. It concluded with an the World Bank dominated the policy dialogue with overall positive assessment of the education the Government. This was the main single source of program and a list of questions that needed discontent from other donors" (Martin, et al., 2p4). to be investigated further, especially on ca- Program development: In parallel to ESDP the pacity. Government also undertook the preparation of the Health Sector Development Program (HSDP - see separate case). Many major meetings and support- Preparation Phase ing studies and design work were shared by ESDP and HSDP. ESDP preparation took place about six (1) May 1997: First joint donor technical assis- months ahead of HSDP, and lessons from the first tance mission. could be taken into account in the second (e.g., size (2) Sept./Oct. 1997: Second joint donor tech- of missions, steps to follow, key documents to pro- nical assistance mission. duce). Development of EDSP can be divided into (3) January 1998: Study on "Implementing Sec- three phases, each with the events listed below:2 tor Development Programs in Ethiopia". (4) February 1998: Third joint donor technical assistance mission (i.e., appraisal). Initiation Phase (1) 1994: Education and Training Policy and Implementation Planning and Strategy prepared by Government; Educa- Negotiations Phase tion Master Plan (20 years) prepared by MOE; Short-Term Education Plan (5 years) (1) April 1998: IDA follow up mission and ne- with focus on primary education. gotiations in the field.3 2Martin, p. 4. IDA wanted wide participation by other donors in this mission, but the government refused to allow any donors to take part unless they would be bound by the resulting IDA agreement-which was not possible. An exception was made for the African Development Bank. 97 ANNEX 6: ETHIOPIA EDUCATION (CASE STUDY (2) May 1998: Study on "Harmonizing Re- central steering committee. The government wanted quirements and Procedures Among Po- only three donors on the committee with a majority tential Funding Agencies Supporting of government representatives. Furthermore, they Education and Health Sector Development wanted decisions by majority votes. This proposal Programmes in Ethiopia," focusing on left some donors out of the deliberations. The three monitoring, reporting, reviews, and evalu- donors could not commit the wider group of do- ations. Board Presentation: May 26, 1998; nors, and could not accept voting as a means of reach- and Credit Signing: June 12, 1998. ing decisions (compared with consensus). In the end (3) September 1998: First complete version of it was agreed that the three donors on the steering Program Action Plan (PAP), a summary pre- committee would be advisors and not participate in sentation of the ESDP; Study on "Financial decision-making on the project. A donors group was Reporting System on the Use of Donor established to facilitate communication among the Funds." donors. (4) October 1998: Program Implementation Level ofsector analysis: As mentioned previously, Manual (PIM). the high level of sector analysis was one of the rea- (5) November 1998: "Debre Zeit II" on both sons for Bank acceptance of the sector-wide ap- education and health. This was a wrap-up proach. Annual public expenditure reviews and a presentation of the final program to mobi- social sector expenditure review were available. In lize the support of other donors. However, particular, the 1997 public expenditure review by the war had started with Eritrea in May 1998, Bank established a medium-term expenditure frame- and further donor support was not forth- work. The bulk of the analysis that preceded the coming. preparation of the ESDP was produced and facili- tated by the PHRD project financed by a Japanese There was no overall plan or "grand design" for grant and executed by the Government. According development of the Program from the stage of do- to Martin (p. 5) the studies developed by the project nor involvement. Nor was it overly prescriptive early generated primary data through household, insti- in the process. An interactive, pragmatic approach tutional, and community surveys and combined this was used. Key documents for agreements included with secondary data from previous studies. The the Program Action Plan (PAP), a five-year plan based majority of the work was carried out by local staff on a summary of the various regional plans, and the and consultants. Nine separate studies were pro- Program Implementation Manual (PIM). The PIM duced, including access to and supply of educational spells out separately all the guidelines for ESDP facilities; demand and supply of educational man- implementation and includes practical guidelines for power; private and social returns to education; de- persons responsible for implementation. Topics cov- mographic analysis and population projections; ered include annual planning cycle; financial man- household demand for schooling; the role of NGOs agement; procurement management; construction and private sector in service delivery; costs and fi- management; and monitoring and evaluation. nancing of education; community consultation; and The main substantive issue between IDA and the participation; and cost effectiveness of key educa- government had to do with vocational training. The tional inputs. In addition, the Bank's Task Team overall program called for rapid vocationalization Leader spent considerable time with other donors of schools. IDA raised questions about cost and link- to assemble analyses done by other agencies. In par- ages with the labor market. In the end the regions ticular, USAID, the EU (on higher education), and called for studies before adopting the central SIDA (cost-effectiveness of different types of school government's plan. The main procedural or admin- construction) had significant studies and analyses istrative disagreement was over the structure of the that had not yet been widely disseminated. 98 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA Instruments for agreements: The main instru- tutional capacity, but without much success. Dur- ments for agreements were the documents produced ing missions technical assistance was provided. For by the Government (the Plan and Program), the example, by examining the work to be done in trans- agreements reached at a donor conference, and the ferring funds and implementing the program, offi- aides-memoire of the missions. In addition, the PAP cials came to see that the procedures, tasks, and and PIP provided a detailed basis for agreements on capacity required had not been thought through the program and its implementation. Late in the sufficiently. The missions finally were able to achieve program development (at about the stage of effec- some modest success in introducing an institutional tiveness of the IDA Credit) some of the donors, e.g., development component in the expenditure program SIDA, proposed the development of a Memorandum covering support for information systems, human of Understanding (MOU). However, the Govern- resource development, and hardware. ment was not receptive. The Government viewed this Stakeholder consultation: The process of program as just another hurdle and felt that existing docu- development was managed from the top down: first mentation (the PAP and PIP) would suffice. There development of the central policy and framework, was no formal agreement between the Bank and other then preparation of regional plans. Regional plans donors. In retrospect, the Task Team Leader felt that were wholly developed by the various sections of some kind of formal agreement would have been regional education bureaus. However, few regions highly useful at the start of the process of detailed reported significant involvement of lower level stake- preparation, to define roles and responsibilities more holders in the process, other than to provide data clearly. This would have complemented the consid- and information. A few regions held seminars or dis- erable goodwill that existed at that stage. tributed draft plans down to the zonal level for com- Institutional capacity: In the view of the Task ments. One city-region, Harari, had consultations Team Leader institutional capacity was not satisfac- with all its teachers, but in general information about torily assessed during program preparation. In part the ESDP was not widely disseminated during the this was because the government had difficulty preparation process. Few persons outside of regional throughout project preparation in accepting that it bureaus had more than a passing awareness of its had weaknesses in institutional capacity, even under existence. As stated in the QEA, "direct consultations the decentralization program. The Office of the Prime with stakeholders are not evident to have been a part Minister (OPM) did not recognize initially that it of the preparation of the program" (section 4.1). Still, had a problem of institutional capacity to implement the level of participation and decentralization of the the program. The central Ministry of Education planning process for ESDP in Ethiopia was far more (MOE) had been a capable ministry in the past. How- widespread than in other comparable countries. In- ever, it had been weakened by the overall Govern- clusion of some bottom-up processes would have ment program to decentralize public administration. been of great advantage, but would have taken more Many experienced staff either were transferred to time and would have been more difficult to man- regions or left the MOE altogether rather than be age. Many regions are now taking steps to rectify the reassigned. There was no clarity among remaining lack of dissemination, but it is difficult in larger re- staff about the role of a central ministry in a decen- gions (Martin, et al., p. 35). tralized setting. Several regions had reasonable ad- ministrative capacity, but at least three or four regions were almost hopelessly weak. No analysis seems to THE SECTOR-WIDE PROGRAM have been made about incentives of key actors in the implementation of the program (QEA, section 6.1). Objectives and content: The objectives of the first The problem was how to address the weak capacity. five-year phase of ESDP are to improve the overall An external consultant was used on assessing insti- educational attainment of the population while 99 ANNEX 6: ETHIOPIA EDUCATION CASE STUDY achieving greater social equity. The long-term ob- procedures. However, the monitoring, coordination, jective is to achieve universal basic education by 2015. and oversight of ESDP are carried out through bod- Targets for the first phase include increasing the pri- ies created for ESDP. These include a Central Joint mary enrollment ratio from 30% to 50% of the eli- Steering Committee and its Secretariat and their gible population (from 3.1 million students to 7 analogs in the regions, Regional Joint Steering Com- million) with emphasis on rural areas; improving en- mittees and corresponding secretariats (PAD, p. 14). rollment ratios for girls from 38% to 45%; improv- The secretariats, in particular, are responsible for ing efficiency by reducing dropout and repetition monitoring progress, managing information flows, rates; improving quality and relevance by reducing and reporting and approving work plans. Regional the book to student ratio from 5:1 to 1:1 in core sub- Educational Bureaus have the responsibility of imple- jects; and improving financing by increasing public menting about 87% of the program. The QEA re- spending on education from 3.8% to 4.6% of GDP. port observed, "the program relies heavily on steering The central Government has provided the overall committees .... This maybe the best that can be done framework, policy, and targets and each region has in the situation, but steering committees ... cannot developed its own program reflecting local condi- substitute for weak capacity" (section 6.2). tions and aspirations. The sum of the regional plans Modus operandi: The nature of donor support plus the central framework constitute the ESDP. In and supervision is different from project support the primary education program, components include that requires that details of the operation be spelled construction, renovation and upgrading of schools, out and costs determined in advance. For program curriculum reform, teacher training, and book pro- support, the key is agreement on program objec- vision. Secondary education includes expansion of tives and targets, and the process by which these ob- facilities to reduce congestion, curriculum revision, jectives and targets will be achieved (p.l14). The key upgrading of teachers, and provision of instructional process in the sector program is the annual review. materials and equipment. TVET includes employer The purpose is to (1) look backward and review and market surveys of needs. Teacher training in- progress against targets in the previous year and, cludes upgrading and expansion of training capac- based on this and any changes in circumstances, (2) ity, introduction of distance teaching, and training look forward to agree on the expenditure and imple- of school managers. Tertiary education includes ex- mentation plan for the coming year. The QEA re- pansion in limited areas (education, engineering, port noted, "the creative design feature of an annual health workers and public administration, and in- review process to agree on the program for the fol- stitutional analyses of cost-effectiveness. Institutional lowing year provides a mechanism for sequencing, development includes support for planning, exami- prioritizing as well as protection for the Bank" (sum- nations, financial management, implementation, and mary). Inputs required for the process are regional monitoring and evaluation. Key policy reforms in- and national monitoring indicators, annual work clude extending primary education from 6 to 8 years, programs and budgets, and implementation perfor- automatic promotion from grades 1-3, use of local mance as reported in progress reports and validated languages in primary grades, establishment of a new by independent reviewers. Two joint supervision career teaching structure, elimination of fees for missions (jointly held by the Government and do- grades 1-10, and the introduction of cost recovery nors) also feed information into the annual review, in grades 11-12. ESDP also supports the government- as do the results of previously agreed ad hoc reports wide program of decentralization in the education and analyses. Reports by implementing agencies in- sector. clude expenditure data for the previous six months, Organization and management: ESDP imple- data on physical targets achieved, procurement sta- mentation is carried out through existing institu- tus, performance coefficients (achievements divided tions, largely following existing Government by agreed targets), issues, and plans to resolve them. 100 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA The annual review process depends critically on the on actual implementation performance. Part of the quality of information collected, transparency, and understanding between donors and Government is mutual trust. A key part of the annual review pro- that all parties would operate only within the agreed cess is the monitoring indicators. A set of twenty program; no additional donors would be allowed to basic indicators has been developed, including bud- provide assistance outside the agreed framework.' get and expenditures, access, quality, efficiency, and Financialflows and disbursements: Instead of cre- equity (PAD, Annex 7). ating new parallel systems for moving money un- Harmonization of donor procedures is also a der the project, the donors wanted to use key feature of implementation. As stated in the PAD Government channels as much as possible. Some do- (p.12), to lighten the administrative burden on the nors argued for budgetary support, but many do- limited capacity of the Government at all levels, it nors had concerns regarding whether funds would was agreed to harmonize donor procedures for be used for their intended purposes through the supervision, monitoring and evaluation, and Government's own financial systems. Most donors- reporting. These were not fully worked out prior including IDA -wanted to be able to account for to the start of the Program. Common procedures the funds. This required the development of a sys- are not included for procurement, in part because tem to tag the money and report on it for reimburse- work was being done on the topic separately. ments. In the end multiple channels were agreed for However, it did not materialize and now the disbursements."Channel 1" is via the regular finan- government is saddled with different procurement cial system of the government, from the central MOF systems with each donor. to regional Bureaus of Finance and so on. Channel Financing: The ESDP costs about $1.8 billion 1 is subdivided into "la" (unearmarked budget sup- over five years with contingencies, of which the IDA port), and "lb" (earmarked funds). "Channel 2" is Credit will finance $100 million, or 5.6%. Other via the sector ministry, i.e., to the central MOE, then donors agreed (as of 4/1/98) to finance another $180 to regional education bureaus, etc. "Channel 3" is million and the Government contribution is $1.3 directly from the donor to the recipient agency, by- billion, leaving a financing gap of about $220 mil- passing the Government budget system. Several lion. The financing gap is to be filled by other do- donors (SIDA, Norway, Finland, and DFID) ex- nors, or by scaling back the program. The Bank pressed interest in providing donor support. The agreed to be the "lender of last resort" According to condition is confidence in financial management, Martin et al., this has helped smooth relations with reports, and accounting. However, so far none has other donors. However, in practice it has not worked contributed to the project through this channel. The because of delays in getting firm commitments from Bank is using "channel lb," USAID and the Irish are other donors. The program is not fully funded and continuing to disburse funds through Channel 3. the IDA Credit cannot completely fill the gap. The The issue of financial management was identified Bank's financial plan is flexible: (1) It can disburse as early as the second mission, but the Office of the against anything but civil service salaries; and (2) Prime Minister refused to get the MOF and others about two-thirds of the Credit proceeds are involved. They simply wanted donors to use exist- unallocated. Moreover, the pace of disbursements is ing financial systems. An expenditure review helped dictated by the pace of procurement. The Bank can produce an action plan for the improvement of fi- finance more than currently planned per year based nancial management, but its implementation has 4 A complication for IDA has arisen because the Bank's agriculture sector is proposing to add a unit for traditional medi- cine at the agricultural university and it not clear whether it can be added because it was not envisaged as part of the original program. 101 ANNEX 6: ETHIOPIA EDUCATION CASE STUDY been slow. Some offices lack financial systems and cided at the annual reviews. Financing can be ad- others have heavy rates of vacant positions. It took vanced based on good implementation performance. over one year to get Government acceptance of the In effect, the project has "implicit annual tranches" existence of a financial management issue. The Fi- (QEA, summary). A new credit is even possible when nance Ministry is expected to supervise the program most of the current one is used. Disbursements can at regional levels and seek replenishment of special be advanced if the pace of work justifies it. On the accounts. The Government wanted to have a dis- other hand, the Bank has a "slow down" strategy bursement plan for $35 million in the first year. The based on the annual review of performance. For gross Bank staff did not believe this was realistic, assum- distortions or major failure to deliver, the Bank could ing a target of $15 million would be more appro- decline to commit any funds for the following year. priate. However the Bank agreed to give the Also, the donors act in concert. Government the benefit of the doubt on implemen- tation capacity and let the actual pace of implemen- tation determine the level of disbursements. SECTOR PROGRAM IMPLEMENTATION Procurement: The Development Credit Agree- ment calls for normal procurement procedures, ex- Implementation experience: The main event affect- cept that it is 'liberal" about thresholds. ing implementation has been the outbreak of war Risks and dangers: The sector program does carry between Ethiopia and Eritrea. This has caused sev- different risks than a specific investment project. For eral donors that had previously committed to help one thing, the external donors have to be concerned finance the sector program to pull back and delay with policy developments from top to bottom and disbursements. Specifically, the Nordic and U.K. as- from one side to the other in all regions. Under a sistance programs were considering channeling dis- sector program the donors try to use Government bursements through "Channel 1 a", but stepped back systems and procedures as much as possible. For after the war started. In the first year of the conflict financial management this entails a higher risk of the Government maintained its level of expenditures misuse of funds than under carefully controlled on the social sector. However, recent information project accounts. Another risk is the added complex- indicates that major cuts are expected in social spend- ity of dealing with the sector as a whole rather than ing in the second year. The Government did not in- a more limited enclave. One risk pertains to the har- dicate any plan to cut social spending during the monization of donor procedures on procurement annual review. However, shortly after the annual re- and financial management reporting. The risk is that view, cuts of 30% in regional budgets were an- the harmonization may not be comprehensive, there- nounced. These cuts will require backloading the fore placing considerable burden on the disbursement schedule. In addition, a major increase Government's limited capacity at all levels (PAD, p. has taken place in the financing of higher education, 40). However, the project documentation does not ostensibly to improve output capacity in public ad- address the very large risk of lack of capacity of the ministration and teacher training. The extent of the regional and central government. There is no dis- increase was not made explicit during the annual cussion of possible exit strategies (QEA, section 8.2). review. These events have led to suspicions on the Conditionality: Formal targets for education part of the donors that Government representatives financing include an increase from 3.8% of GDP to were not transparent about real intentions during 4.6% and from 13% to 19% of government spend- the review. Thus, transparencyin the process of mu- ing, plus subsector targets (from 46% at present to tual and free exchange of information has not yet 65% of education spending for basic education). The been achieved. main conditions relate to the implementation of the An instrument is needed to provide transpar- agreed annual work program, as evaluated and de- ency, so everyone can see all documents and reports 102 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA without harboring suspicions about ulterior motives. change in quality that occurred in the pro- As a result of the war, efforts at the harmonization cess. For example, regions introduced new of procedures by donors have stopped. Experiences strategies for non-formal education that with the annual review cycle reveal weaknesses in re- were not originally envisaged. The capacity porting. In particular, the annual review did not re- building achieved has been enormous in ceive complete information on expenditures over the terms of regional planning. previous six months. The monitoring and informa- (5) Even though more consultation could have tion systems need further work to function properly been done, the extensive educational plan- and indicate weaknesses in local capacity to produce ning done in regions contributed greatly the required reports. In contrast with a Government to broadening stakeholder participation, target of $35 million in disbursements for the first and understanding and ownership of the year, only $12 million was disbursed in the first year, program. including retroactive financing. The Government (6) The dialogue has had an impact on policies wanted to have an allocation of $55 million for imple- and goals; for example, plans for vocation- mentation in the second year, but only got $35 mil- alization of secondary schools have been lion including a rollover of unspent funds from the toned down as a result of discussions dur- first year. Despite all the preparations, the MOE had ing which international experiences were ex- to request a supplemental budget to put IDA funds plained. into the budget. This delayed implementation. POSSIBLE LESSONS OUTCOMES SO FAR AND FINAL OBSERVATIONS Main achievements: ESDP is the first sector program in the education sector that is truly sector-wide in scope, and the first (1) One clear achievement has been the comple- to commence from the Government's own policy tion of the preparation process for the pro- framework (Martin, et al., p. 30). gram. It is widely seen an as innovative program and many donors have indicated (1) The main conditions contributing to the interest in participation. success of the program development and de- (2) The number (16) of donor agencies agree- sign were (a) the macro framework, which ing on the content of the program. allowed the program to develop within a (3) Government ownership of the program and growth economy; (b) the extensive knowl- the process and the consensus achieved- edge of the sector and its problems; and although it was from the top down from the (c) the client taking leadership over the pro- PMO to Regions, Zones, Districts, and cess. It may be unlikely that a sector pro- then to schools. The initial decision to em- gram will succeed without these conditions. bark on an ESDP was entirely on the (2) Considerable continuity of core personnel Government's own initiative and was with- on both the Government and donor sides out pressure from the donor community during program preparation was an impor- (Martin, et al., p. 39). tant factor in its success. It allowed for the (4) Perhaps the most significant achievement establishment of trust and good working is the quality of regional plans developed relationships (Martin, et al., p. 46) throughout the country. A comparison of (3) A formal agreement would be highly use- original with final drafts shows the sea ful at an early stage to define roles and re- 103 ANNEX 6: ETHIOPIA EDUCATION CASE STUDY sponsibilities of both donors and the cli- with differences on procurement and espe- ent. This should include the role of the lead cially financial management. These were the donor, if any. This would have helped to most contentious areas throughout the avoid later disputes, e.g., level of donor rep- preparation of ESDP. It would have been resentation in the steering committee. The useful if the PIM, financial management amount of time required for consultation study, and harmonization studies could have with donors cannot be overestimated. The occurred earlier. partners need to be kept informed, their (10) It is advisable to see harmonization and inputs need to be used and consensus needs integration with donor procedures as a me- to be achieved. The transaction costs are dium-term process that will pass through a enormous. series of transitional forms (Martin, et al., (4) Since the sector program does not define p. 47)- such as the multiple ways financial all activities and have everything in place flows were organized for ESDP. in advance, the mechanisms for dialogue and ( 11) The financial contributions of the various deciding these matters during implemen- donors differ considerably and this almost tation become of overriding importance. invariably means varying amounts of influ- (5) The process of getting mutual understand- ence inpolicydiscussions. In the ESDP some ing of the issues and resolving them cannot donors felt left out and that the policy dia- be done overnight, as evidenced by the one logue process was dominated by the Bank. year it took for the OPM to recognize there This suggests that a forum should be part was a problem with financial management of program design for specifically discuss- capacity. ing education policy issues on the basis of (6) The ESDP had targets for the end of the pro- relevant professional experience (Martin, et gram, but not interim targets against which al., p. 44). to measure year-by-year progress. (12) Sector-wide coverage means that technical (7) The Bank does not have to take the lead in and vocational education training, and sector program development on the side of higher education are included, areas in donors. If it does, it should be prepared to which achieving consensus is much more spend extra resources to ensure that tech- demanding than basic education. It also nical gaps are filled and ensure full consul- means greater complexity and possibly tations. In the case of Ethiopia education greater difficulty in implementation. How- the preparation cost $600,000 compared ever, a sector-wide approach also allows the with $350,000 on the average. donors to check whether subsectoral allo- (8) The capacity of other donors to deal with cations of the education budget are appro- technical issues and policy dialogue is of- priate, e.g., for higher education. This would ten limited. One the one hand consultants not be easy if only one subsector, e.g., basic are often used for technical work, but are education, were included. not authorized to speak for the donor on (13) Throughoutprogramdevelopmentpercep- policy issues. On the other hand, donor staff tions differed widely between the govern- sometimes are ill-prepared for policy dia- ment and donors on the management logue themselves. capacity and institutional requirements of (9) It was relatively simple to harmonize moni- the implementing agencies, including finan- toring and progress reporting and move cial management procedures of the govern- toward jointly conducted reviews and evalu- ment. These disagreements delayed analysis ations. It was much more difficult to deal of critical issues, such as financial manage- 104 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA ment, and delayed agreements on the ex- success of the ESDP depend on the Bank tent of technical assistance needed to build and Borrower's ability to prioritize, focus capacity. The gap in perceptions could have and sequence the effort into more manage- been narrowed or closed by starting with able elements" (summary). The annual re- an analysis of institutional capacity (al- view process provides a mechanism for though admittedly it would have been dif- doing this. ficult to persuade the government to accept and participate in such a study). The ESDP did not have everything ready and com- BIBLIOGRAPHY pleted by the time of Credit approval. A sec- tor program, unlike a project, simply will Martin, John, and Riitta Oksanen, and Tuomas not have all the details completed by the time Takala. 1999. "Preparation of the Education Sec- of commitment. The difference is that a sec- tor Development Programme in Ethiopia: Re- tor program creates a framework for the dia- flections by Participants." Cambridge Education logue on issues. The question is: what is the Consultants, UK and FTP International, Finland. critical threshold for going ahead with the Final Report, 7 June 1999. program? In the case of the ESDP the IDA World Bank. 1998. "Program Appraisal Document team was satisfied that it had 80% of what on a Proposed International Development As- it wanted. It would take another five years sociation Credit in the Amount of US$100 Mi- to get the rest. The process for dialogue al- lion Equivalent to the Federal Democratic lows for the lose ends to be tied during Republic of Ethiopia for the Education Sector implementation. Development Program." Human Development (14) The QEA pointed out that the government's IV and Country Department 6, Africa Region, development of the strategy before donor Report No. 17739-ET, May 4, 1998. involvement means strong borrower com- World Bank. 1999. "Quality at Entry Assessment: mitment. However, "ultimately the Bank has Guidance Questionnaire" as part of the Quality to weigh client responsiveness against a very At Entry Report for CY 1998, on the Ethiopia complex (and inadequately sequenced) Education Sector Development Program. (Com- strategy in a context of weak capacity and municated by Dora Aku Adoteye to Prem Garg, with multiple donors. ... The prospects for EM 10/8/99.) 105 ANNEX 6: ETHIOPIA EDUCATION CASE STUDY TABLE 1 732 - Ethiopia, Education Sect. Inves Project Status Report Date: 2/26/99 Region: AFR Country: ETHIOPIA Sector, EP Lending Instr: SIM Prg Obj Cat: PA EA Cat: C PTI? Y NGO? N Resettlement? N LOAN INFORMATION Agree LICIG Rev'd Curren: Prod Signing Effective :ffSupPr Type No. rAnt A:n :ndicaor Line Date Dati I IDA 30770 74.30 (SDR) PE 6/4/98 12/2/98 Ttal Orngina Amnount(SDR)i: 74.30 To tal eviHsed Amount (S D: 0.00 COFINANCING INFORMATION Agency Board Amount ($M) ~~~~CurrntAmou1nt ($M Total 0.00 0.00 Garante Type: Guar ateeAount ($MII: This form is part of: Initial Summary Read togethe with:. Aide-memoire Missiont End Date This Form PSR Date: 2/26/99 BTO memo of: Months sine last misssion: Last Form PwSRDate: )Follow-up letter of: Next mission planned: 7/1/98 Total Field SUPERVISION Sta f- Total Stff- BoFld As of EFFORT Weksk $000 Weeks $000: 2/6/99 Current FY - Planned 56.70 195.73 Current FY - Actual 14.35 63.58 0.00 0.00 Board through preceding FY 0.00 0.00 0.00 0.00 Toa Actual 14.35 63.58 0.00 0.00 No. of ~~Role or Preou UPINo. Mi0ssin Member Division FIdDys Sp a Msi 106 ANNEX 7 The Gambia Education Case Study' First Phase of the Third Education Sector Program ACRONYMS school leavers, and adults. During the 1990s the Gov- ernment increased public expenditures on educa- DFID Department for International tion at 10% annually in real terms. This resulted in Development an increase in spending on education from 15%-2 1% DOF Department of Finance of total government expenditure and from 2.6% - DoSE Department of State for Education 4.3% as a share of GDP. The proportion devoted to EU European Union primary education also increased from 38% to 45% PAD Project Appraisal Document of the education budget. Gross enrollments in grades SIP Sector Investment Program reached 70% in grades 1-6 and the transition rate SWAP Sector-wide approach from grade 6 to 7 increased from 35% to 70%. Development of the education system is affected by several exogenous factors, including high popu- BACKGROUND lation growth, which makes it difficult to keep up with service provision, limited public revenue and The Government developed a 15-year strategy to im- high debt service (30% of recurrent expenditure), prove education in the late 1980s, the Sector Policy which limits public resources available for educa- Framework (1988-2003). The priorities were to (1) tion, and high levels of poverty in rural areas which increase the gross enrollment ration in grades 1-6 affects the demand for education. The main issues to 75% and the transition rate from grades 6-7 to internal to the education system are: (a) the need to 60%; (2) lower the school entry age from 8 to 7; (3) expand enrollments by 8% per year to reach a 90% develop a broad-based curriculum for basic educa- gross enrollment in the nine-year basic education tion (grades 1-9); (4) improve the quality of learn- by 2005, including accommodating an additional ing in the basic cycle by upgrading all unqualified 175,000 students, and overcoming barriers to atten- teachers, increasing expenditures on learning mate- dance particularly among girls and the poor; (b) un- rials; (5) increase access to post-secondary vocational clear effectiveness of education in terms of learning training and coordinate its provision better; and (6) achievements of students; (c) questionable equity increase opportunities for out-of-school youth, and efficiency of public financing of education, in 'This case is based on interviews with Ms. Rosemary Bellew, Task Team Leader, and the Project Appraisal Document, "Third Education Sector Project In Support of the First Phase of the Third Education Sector Program," August 7,1998, Report No. 17903-GM. 107 ANNEX 7: THE GAMBIA EDUCATION CASE STUDY terms of available spending for poor students, in- the necessary subsectoral linkages and result in a poor sufficient expenditures on improving learning con- mix of products (PAD, p. 15). The sector-wide ap- ditions, undersized classes, and high expenditures proach permitted the bank to seek policy objectives on untargeted subsidies (PAD, pp. 5-6). in higher education that otherwise would have been The second half of the 15-year policy period off-limits in a sub-sector approach. Specifically, the maintains the same priorities and builds on these Bank has been discussing policies on reducing sub- accomplishments while pushing for a target of 90% sidies and introducing cost recovery in post-second- of the school age population enrolled in the 9-year ary education. (PAD, p. 12). Finally, it was felt that a basic cycle by 2005. It also pursues interventions to sector-wide approach would help overcome some improve equity, effectiveness, efficiency, and build- of the other problems associated with past projects, ing sector management capacity as well as issues in namely: overall weak management, planning, moni- higher education and sector financing. The Govern- toring, and evaluation combined with a lack of con- ment's objectives and strategies for addressing the sultation with stakeholders that resulted in poorly issues have been refined and elaborated in the fol- mapped-out strategies and implementation plans, lowing documents: Revised Education Policy, 1988- lack of clearly defined responsibilities, the question- 2003, which updates the original policy, the draft ing of some strategies, and incomplete implemen- Master Plan and Investment Program, 1998-2005, tation or a reversal of the policy decision. The which describes priority programs, resource require- sector-wide approach involved extensive stakeholder ments, implementation responsibilities and sched- consultations, preparation of annual implementa- ules, and the Public Expenditure Review, 1998, which tion plans and annual review of program implemen- lays out policy decisions regarding intra-sectoral fi- tation, and strengthened administrative capacity, nancing (PAD, p. 8). such as for monitoring and evaluation (PAD, pp. 17-18). Lending instrument: The program lent itself to SWAP DESIGN an Adaptable Program Lending (APL) instrument, as a transition toward a Sector Investment Program Rationalefor a sector-wide approach: The reasons for (SIP). (1) As noted above, the program is sector-wide adopting a sector-wide approach are rooted in the in scope. (2) It includes well-defined overall objec- shortcomings of previous project lending. The PAD tives, strategies, and programs. Several of these need states that a project approach to the development of further conceptual work, planning, and budgeting the sector led to insufficient ownership and integra- (particularly vocational training and higher educa- tion of project activities into the DoSE's work pro- tion), and thus are deferred to a second phase. (3) gram (p.17). In addition, a sector-wide approach is Medium- and long-term public expenditure plans adopted because of the negative effects of focusing have been estimated taking into account the macro- in the past on only one subsector (basic education) economic framework. (4) Local client is in charge through separate small projects. Projects limited to of the process. However, the following elements of a basic education had two negative effects: (a) donor SIP were not fully present: (a) all main donors agree concentration of funds in one subsector meant that to the program and commit to finance a share of public development expenditure, being fungible, was the costs; (b) harmonization of donor requirements directed at other levels of education; and (b) devel- and procedures; and (c) reliance on normal govern- opment of the whole sector was not monitored. ment institutions and procedures for such things as Moreover, the pad points out that all levels of edu- procurement and financial management. Specifically, cation are linked to each other pedagogically and all the DoSE did not have the initiative to effect strong derive resources from the same budget. Development coordination of donors. Only a limited number of of one subsector at the expense of others can distort multilateral and bilateral partners were interested in 108 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA supporting the sector, and the volume and timing Ministry of Finance led the overall expenditure re- of their support was uncertain. Existing government view. The Bank and DoSE worked together to ana- capacity for management, monitoring and evalua- lyze expenditures and the MOF participated in tion capacity was considered relatively weak (PAD, discussions of strategy development. The DoSE took p. 15). Measures are included in the first phase to the driver's seat in the preparation of the strategy build necessary capacity as the program progresses. and plans. The revised policy framework, investment Preconditions: Several factors were important in program, and implementation plan, supported by a the decision to develop a sector-wide program ap- public expenditure review, were prepared by the proach. First, the Government had achieved a rea- DoSE with little or no input from technical assis- sonable level of macroeconomic stability that tance. Initially, the DoSE was not well organized to provided a context for medium term planning of carry out this work, but the Permanent Secretary ap- expenditures. Second, the Government had devel- pointed a highly competent person to take charge oped a 15-year policy framework which was decent of the work and the senior management team- and well done. The overall plan both demonstrated which existed previously but was not functioning- the Government's commitment to the process and provided the linkage between the overall picture and the basic competence to develop reasonable strate- specific components throughout the process of de- gies and programs. The Government was about velopment. (b) To ensure a high level commitment, halfway through the implementation of the plan. the revised policy framework and investment pro- Third, a social sector expenditure review had helped gram were discussed with and approved by the Na- build some capacity locally on how to do expendi- tional Assembly. (c) In addition, a cabinet paper has ture analysis. This analysis revealed the lack of con- been prepared and discussed to ensure appropriate gruence between policies and expenditures. Fourth, support for budgetary allocations (PAD, p. 18). In the Bank had a long history of dialogue with the Gov- the end it was clear to all that the Gambian side had ernment through its previous two projects in edu- prepared the strategy, program, and plans, not ex- cation, the last of which allowed the start of ternal donors. discussion on policies. Fifth, the Bank had a consis- Donor coordination: This was a relatively unique tent team, with whom the Gambian officials had situation for Sub-Saharan Africa. About ten donors2 gotten comfortable with. The level of confidence and have been active in The Gambia or have plans for trust allowed the Bank to push on issues, both with projects in the near future. However, for various rea- the DoSE and the Finance Ministry. sons, including the political situation, not a lot of Definition of the sector: The "sector" includes all donors were clamoring to provide support to the education and training at all levels. Specifically the overall program. Initially the Bank did all the donor sector is defined to include basic education, early coordination and worked closely with other agen- childhood development, secondary education, vo- cies such as UNDP, UNICEF, ADB, and WFP. How- cational education and training, university educa- ever, by the time of appraisal the DoSE had appointed tion, adult education, and management and a donor coordinator. During appraisal, the DoSE administration. All these subsectors are under the convened partners to discuss modalities for partner purview of one Ministry, the Department of State coordination. The DoSE decided that donor coor- for Education (DoSE). dination would be the responsibility of a team com- Program leadership: Leadership, ownership, and prised of the DoSE coordinator, a representative of commitment have been demonstrated in a variety the external financing partners, the NGO commu- of ways by different Government entities. (a) The nity, the Department of Finance, and the Office of 2ADB, DANIDA, DFID, EDF, IDB, OPEC, UNDP, UNICEF, WFP, and the World Bank. 109 ANNEX 7: THE GAMBIA EDUCATION CASE STUDY the President. UNICEF was appointed to represent key issues and select policies, programs, and resource the donor community. No major disagreements oc- requirements. The analyses underpinning the iden- curred among the donors. The DfiD and EU initially tification of issues and choice of strategies and ob- were reluctant to participate for political reasons, but jectives are contained in household surveys, eventually agreed to participate on a small scale. preparation studies, and other sector work carried Program development: Preparation of the Pro- out during implementation over the past ten years gram took place piece by piece. The Bank helped during the implementation of the first half of the Gambian officials analyze and work through vari- investment program (PAD, p. 8). Specific studies were ous issues. It was important that Bank staff were generated during program preparation on subsidies available frequently for assistance and as a sounding to private schools, school feeding, overstaffing, in- board. This involved frequent missions. The key steps efficiency of the Gambia College and heavy subsi- were as follows: (1) In 1995 the DoSE undertook its dies to students in tertiary education. The DoSE had own review of progress under the 15-year program developed data collection that permitted time-se- to determine what worked, what did not, and issues ries information to underpin the analysis. that needed to be addressed. Discussions were held Institutional capacity: One of the unique char- in regional districts and culminated in a national acteristics of the Gambia education APL is the sys- conference at which conclusions were drawn. (2) tematic evaluation that was done of institutional Several specific evaluations were undertaken of such capacity. This followed a methodology that analyzed topics as double shift teaching and the book system. all the proposed activities in the Program in terms (3) The work on the public expenditure review with of five criteria: whether (a) the functions and activi- the Bank helped identify some additional issues for ties have an appropriate organizational home; (b) study. (4) As the results came in from the above spe- the level of leadership and management is effective; cific studies, the DoSE prepared the Revised Policy (c) sufficient operating funds are available for the Framework. (5) In parallel, the DoSE started work- implementation of assigned activities; (d) the unit ing on the program document, with assistance from has the right number of people with the right mix the Bank on a step-by-step basis, i.e., analysis of causes of skills-based on a workload analysis; and (e) key of major problems, examination of options in terms work practices are efficient and effective. This as- of cost and possible impact. This step included pre- sessment identified several capacity gaps. For ex- appraisal. (6) Appraisal focused on finalizing costs, ample, the analysis found that curriculum reaching decisions on cost recovery and teacher train- development and in-service teacher training had ing and preparation of the implementation sched- improper management responsibility outside the ule. In this process the Government took several basic MoSE. Another example, in terms of work practices, decisions on thorny issues, including: cutting back was the weak coordination among units in the DoSE. the number of unqualified teachers, reducing subsi- The next step was to consider alternatives to fill the dies for school bus service, cutting subsidies to post- capacity gap through (i) changed practices and pro- secondary students, attaching the issue of the high cedures, (ii) spreading activities over a longer time cost of examinations and scaling back and targeting -including the introduction of a two-phase ap- the school lunch program. proach and postponement of some activities to the Level of sector analysis: The three key statements second phase; (iii) reallocating financial and human of objectives and strategy for the program3 identify resources; and (iv) reducing the scope of the devel- Revised Education Policy, 1988-2003; the draft Master Plan and Investment Program, 1998-2005; and the Public Expendi- ture Review, 1998. 110 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA opment objectives. In the end the Gambia educa- struction and rehabilitation of facilities, expansion tion APL included a detailed analysis of all major of double-shift and multi-grade teaching, improve- institutional components involved in the overall pro- ment in the supply and deployment of teachers, in- gram and detailed capacity building measures (PAD, centives and subsidies for the poor and girls, an E4 and Annex 5). increase in the proportion of female teachers, wider Stakeholder consultation: Considerable stake- distribution of textbooks and teaching materials, and holder consultation took place in the design of the the development of a national assessment system and Program. The process began in 1996 with regional improvements in examinations. focus groups, followed by a national conference. Organization: The DoSE is responsible for the Drafts of the program documents were discussed implementation of the overall program and the IDA with NGOs, the teachers' union, representatives of Credit. It does so through an interagency Project Co- the madrashas, the cabinet, the National Assembly ordinating committee, which it chairs, and a Coor- and key development partners (PAD, p. 8). dination committee made up of representatives of the various units within DoSE. A Project Coordina- tion Unit (PCU) in the DoSE communicates with THE PROGRAM donors, coordinates program inputs, oversees pro- curement, provides financial management of IDA Objectives, strategy, and content: The IDA Credit sup- funds, and submits reports to all donors. The PCU ports the implementation of the second half of the previously existed as a project implementation unit. Government's long-term education program, i.e., It was integrated into the MoSE and its terms of ref- over the period 1998 and 2006. The IDA assistance erence were changed to purge all functions pertain- is divided into two four-year phases. The Program ing to implementation. Most4 implementation seeks to achieve a gross enrollment ratio of 90% in functions were "mainstreamed" to line agencies. nine years of basic education; an increase of girls' Modus operandi: Partner coordination meetings enrollment and retention in the first twelve grades; take place at four-month intervals. The DoSE orga- improvements in the quality of basic education as nizes an annual meeting of all participating part- measured by achievements on standardized tests; de- ners and the Department of State for Finance in May/ velopment of a program for early childhood devel- June each year. The purpose is to review (a) the opment; increasing the gross enrollment ratio in progress in the implementation of the program, in- secondary education from 16-25% along with im- cluding staffing and expenditures; (b) the program provements and reductions in unit costs; improving of activities for the following school year; and (c) the relevance of technical and vocational education the draft development and recurrent budget. Changes through market surveys, policy development; up- can be made in the program and budgets revised grading of selected post-secondary programs to de- based on actual experience and current circum- gree level in fields in demand; development of adult stances. The monitoring and evaluation arrange- educationprogramsandbuildingsectormanagement ments are extremely important for the annual through improved organization of the DoSE, meetings. A set of quantitative monitoring indica- strengthened leadership, adjusting key work prac- tors (Annex 4 of the PAD) has been developed per- tices, raising staff skills, and better mobilization and taining to access, internal efficiency, budgets, resource allocation of funds. These objectives entail new con- utilization and expenditure, and availability and use 'The management of school construction remains in the PCU for the time being because the DoSE does not have an infrastructure unit in which this function could be mainstreamed. 111 ANNEX 7: THE GAMBIA EDUCATION CASE STUDY of instructional materials. The DoSE updates these Risks and dangers: No special risks are identi- indicators annually, and prepares a comprehensive fied in the PAD with regard to the sector-wide ap- report on implementation performance before the proach. Sustainability of project benefits depends, annual meeting. A Management Information Sys- in part, on the avoidance of parallel programs sup- tem is being developed, to be operational by 2001/2 ported by off-budget expenditures (PAD, p. 22) to assist with this work. The Program does not yet and continued stakeholder consultation and feed- entail much in the way of harmonization of proce- back. Implementation of the management capac- dures among the various donors, but supervision ity building component is seen as an antidote to missions would be conducted jointly among the the danger of weak implementation capacity of the donors. DoSE. Financing,flow offunds, and disbursements: The Conditionality: Apart from routine conditions overall program fits within an agreed expenditure related to accounting procedures, appointment of framework. IDA financing is being provided in two auditors, and signature of contracts with supplier phases: $20 million for phase 1 (1998-2003) and $20 organizations, the main conditions under the APL million for phase 11 (2003-2007). The total cost of relate to triggers for the second phase of the pro- phase I is $51.3 million, of which the government gram. These include: would finance 18%, the Bank 39% and other do- The triggers mix substance and process, of highly nors 43%. The bulk of the Bank's funds in the first specific and unidentified targets. The key process of phase (64%) would be allocated to basic education, annual review and planning meetings is stressed, as with 5% for secondary education, 3% for university is the use of common indicators. Annual agreements education, 1% for adult education, and 9% for sec- on budgetary allocations are also stressed, and the tor management. In effect, the Bank's financing is specific targets are included in the master budget- fLxed for the first two years of implementation - simi- ary plan and policy document that is cross-referenced lar to a Specific Investment Credit-but may be in the Credit Agreement. No conditions were in- shifted during annual reviews based on performance, cluded on vocational training or higher education.5 immediate priorities, and the interests of other do- Apart from the standard suspension and cancella- nors (i.e., if other donors wish to finance certain as- tion clauses, the Bank's main leverage and "remedy" pects of the program, IDA funds can be shifted to is in (a) varying the level of funding for the next other priorities). In addition, 16% of the Credit pro- year agreed on during each annual review, and (b) ceeds are unallocated for the second two years of whether to proceed with financing the second phase the first phase and will be allocated during annual of the APL. reviews (PAD, p. 15.) The support by other donor partners was not set at the time of the Credit com- mitment. IDA Credit funds are administered as in SWAP IMPLEMENTATION traditional projects, using statements of expenditures for relatively small purchases and a special account. Implementation experience: Supervision of the Credit Procurement also follows standard IDA practices for has been passed on the Bank's side from headquar- specific investment projects. ters to the Bank's resident mission in Senegal-in On higher education, the Bank team felt that the risk for creation of a big university, as pushed for by the Presidency, was not great: After much discussion a phased plan had been agreed on to create a university in phases, starting with only two or three areas of demonstrated demand. Besides, there were no funds to support a major expansion. On vocational training the Government was not proposing to invest until studies were completed on better utilization of existing capacity and the roles of the public and private sectors were clearly delineated. 112 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA TABLE 1 Trigger Indikor Donor coordination is effective + Annual review meetings organized and held by DoSE . Common monitoring indicators adopted and used Access to basic education is increased + Three-fourths of IDA-financed classroom construction is completed Textbook recycling and rental systems 'C. All students in grades 1-6 have a set of textbooks are functioning to use free of charge + Rental recovery rates not less than 85% for grades 7-9 Teacher training capacity increases + Gambia College takes in 300 PTC and 150 HTC teachers annually Sufficient recurrent budget is allocated + Annual budgetary allocations materialize as agreed to education Source: PAD, p.4. part to reduce the administrative costs of supervi- prevailing fragmentation within the depart- sion and facilitate closer monitoring of implemen- ment previously. tation. Some problems were experienced during the (3) Donors also reached common agreement on startup phase. The Minister and Permanent Secre- the program, which bodes well for avoid- tary (PS) changed. The PS in particular was not up ing the fragmentation of the past. to the job. This slowed progress several months, even (4) Ownership: The DoSE made sure that ev- though the technical people on the Government side eryone knew it was their program, not that were the same. However, in December 1998 a new of donor agencies. In the past projects were PS was appointed who previously had led the tech- referred to by the donor, e.g., an ADB project nical work on the project. Since then things have or an IDA project, not a client-owned started to move. The first annual review was sched- project. This program was different - it was uled for the fall of 1999. owned by the people who prepared it. This Main achievements so far: It is very early in the can be seen by the enthusiasm of the staff implementation of the program, but some accom- to be engaged in the program development plishments can be noted for the design and prepa- and implementation. ration stages: (5) Integration: Transforming the project implementation unit into a coordinating (1) Several significant policy decisions were and support agency, integrating it within the taken on issues that had been hanging DoSE and mainstreaming implementation around for a long time, including unquali- functions with line agencies. fied teachers, subsidies of school bussing, (6) Significant capacity building occurred. Staff school meals and subventions for students were trained and became capable on mod- in higher education. eling through the public expenditure review. (2) DoSE staff got together behind the pro- Staff were trained in workload analysis and gram, based on their participation in its de- analysis of gaps in institutional capacity. velopment and understanding of its Study tours for staff were undertaken on contents. This cohesion contrasts with the school effectiveness issues, economic analy- 113 ANNEX 7: THE GAMBIA EDUCATION CASE STUDY sis, educational technology, and issues in chances for successful implementation of the higher education.6 An expenditure model program. was developed that follows the normal bud- (2) The use of a computerized model can serve get categories and can be used for future a dual purpose: in addition to the evalua- projections and provide rolling guidance on tion of strategic alternatives it can also help whether budgets are on track. track the key monitoring indicators during (7) One major achievement is the systematic implementation. analysis of institutional capacity that took (3) The startup experience for the Gambia Pro- place during pre-appraisal and appraisal gram demonstrates the importance of con- and successfully identified the important tinuity of staff on the Borrower side. The gaps in structures, procedures and resource situation was saved, in part, owing to the allocations for the implementation of the widespread consultation of stakeholders in program. the design phase, and the wide participa- tion of technical specialists within the DoSE. Main problems: The main problem in the de- (4) The importance of frequent contact between sign stage had to do with the capacity of local staff government officials and specialists from the and institutions to prepare the program. It was dif- Bank (as opposed to periodic missions). ficult or impossible to find good economists or lo- (5) The Government also emphasized the im- cal architects. The organizational culture militated portance of good technical skills on the mis- against staff working together and communication sion and proper timing of the visits. systems had to be designed to keep information flow- (6) Several Gambian officials observed that it ing to all parties. would have been helpful to have had the preparation strategy mapped out at the start. In that way everyone could see where it was OBSERVATIONS AND POSSIBLE LESSONS headed and what it involved. However, if the process had been mapped out from the start (1) The importance of thorough institutional it may have appeared overwhelming and analysis as a means to identify areas in need new tasks might not have been as easily ac- of strengthening, and thereby enhancing, the commodated. 6 The study tours travelled to (a) Colombia and Chile for "escuela nueva" (multi-grade teaching, modular curricula, etc), student assessment systems, decentralization, voucher schemes; (b) Washington for a range of topics-logical framework, higher education, education technology, economic analysis, and public expenditure reviews; (c) Addis Ababa for distance education for teacher training courses; (d) Mauritania for community-managed school construction programs; (e) to Senegal for adult literacy programs provided by non-government providers, and student assessment; (f) Ireland for higher education. 114 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA TABLE 2 35643 - The Gambia, Third Education Project Status Report Date: 6/12/99 Region: AFR Country: GAMBIA Sector: EY Lending Instr: APL Prg Obj Cat: PA EA Cat: C PTI? Y NGO? N Resettlement? N LOAN INFORMATION Agree LICIG Rev'd Currency Prod Signing Effective Suppl Prj Type No. OrigAmt Amt Indicator Line Date Date ID IDA 31280 15.10 (SDR) PE 9/22/98 3/22/99 Total Original Amount (SDR): 15.10 Total Revised Amount (SDR): 0.00 COFINANCING INFORMATION Agency BoardAmount($M) Current Amount ($M) Total 0.00 0.00 Guarantee Type: Guarantee Amount ($M)- This form is part of: Supervision Mission Read together with: Aide-memoire Mission End Date: 5/16/99 This Form PSR Date: 6/12/99 BTO memo of: Months since last mission: Last Form PSR Date: 5/4/99 Follow-up letter of: 5/25/99 Next mission planned: 10/1/99 Total Field SUPERVISION Staff- Total Staff- Field As of EFFORT Weeks $000 Weeks $000 6/12/99 Current FY Planned 0.00 0.00 Current FY - Actual 18.15 69.22 1.00 9.09 Board through preceding FY 0.00 0.00 0.00 0.00 Total Actual 18.15 69.22 1.00 9.09 No. of Role or Previous UPI No. Mission Member Division Fid Days Specialization Mission 18303 DIAWARA AFMSN 10.0 SR. OPS. OFFICER Y 22339 DIOP AFTH3 6.0 EDUCATION SPEC. N 89807 TOURE AFMSN 3.0 PROCUREMENT SPEC. N 52149 HAGO AFTH2 14.0 EDUCATION SPEC. N 184936 NDIAYE AFMSN 3.0 FINANCIAL MGMT SEP. N 115 ANNEX 8 Mozambique Education Case Study' Education Sector Strategic Program (ESSP) The impetus for preparing the SWAP was Govern- Low quality ofprimary and secondary education: ment's desire to develop a coherent strategic frame- Low quality constrains the efficiency of the system work and a coordinated structure for the and limits the number of well-qualified students reconstruction and further development of the sec- graduating from each level. Only 54% and 37% of tor following the civil war. The response to dealing students pass the grade 5 and grade 7 examinations, with the devastation of physical assets and social dis- respectively. Although improving, internal ineffi- ruption that had taken place during the war was ad ciency is apparent in high repetition and dropout hoc and piecemeal. Bilateral and multilateral agen- rates and low completion rates. Barely 25% of stu- cies and NGOs responded by providing assistance dents who enter the first grade successfully com- directly to beneficiaries using their own unique so- plete the five grades of lower primary. Only 7% of lutions to problems. As the country settled after the pupils enrolling in grade 1 complete grade 5 with- war it was difficult to systematically link the out repeating. Even those students who manage to government's sector and fiscal policies with the ef- stay in school are not learning enough because in- forts of external donors because of lack of informa- adequate, bare facilities do not create a classroom tion and sometimes conflict in approaches. environment conducive to learning, and multiple The World Conference on Education for All shifts reduce learning time. The number of learn- (Jomtien) was an added impetus for the Govern- ing hours per pupil per year has decreased by about ment of Mozambique (GOM) to develop a number 30% (from 850 to 595 hours) in lower primary edu- of subsector master plans. cation in recent years in some schools. This is lower GOM's concern with increased coordination than the modest 780 hours recommended by coincided with disenchantment on the part of the UNESCO. donors about the increasing ineffectiveness of their assistance. As the volume of aid increased, it became difficult for the country to absorb assistance with- SITUATION PRIOR TO ESSP out a coherent strategic framework, and GOM's ca- pacity to coordinate assistance from a multiplicity Prior to ESSP external assistance to MOE was pro- of sources was stretched. Agreement on a SWAP vided under more than 150 different projects and approach was therefore mutual. subprojects, by more than 16 countries, numerous 'This case was drafted by the ESSP Program Secretariat with inputs from the Minister of Education, Hon. Minister Nhavoto, as supplemented by an interview with the Task Team Leader, Mr. Donald Hamilton and Operation Officer, Mr. Soren Nellemann, plus information from the Project Appraisal Document (PAD), January 22, 1999. 117 ANNEX 8: MOZAMBIQUE EDUCATION CASE STUDY UN agencies,3 multilateral financing institutions,2 SECTOR PROGRAM CHARACTERISTICS international bodies4 and a large number of local and international NGOs operating throughout the The ESSP is sector-wide in terms of the agreement country. In addition to the inability of the govern- between government and donors on the priorities ment to monitor the large number of projects, there for allocation of resources and the main thrust of were serious inequities in resource allocation to the strategy at the different levels of education. The schools, districts, and provinces, and more impor- decision to limit the ESSP to basic education at this tant, resources were often not geared toward urgent stage was because of the absence of detailed strate- priorities. In addition, the numerous PIUs and ex- gies and programs for the other two subsectors. The ternal agencies carried out similar exercises such as overall cost of the program and its financing is in- audits, supervision, etc., drawing heavily on the lim- cluded in the Medium-Term Expenditure Framework ited Government capacity, thereby reducing the (MTEF), and was agreed upon by all stakeholders. Government's resources to undertake their admin- This is the basis on which donors agreed to share istrative function. This was compounded by the use the costs of the program. of different procedures and financial management Decentralization of the management of educa- systems by donors in parallel operations. tion is one of the key objectives of GOM's strategy and this is based on gradually empowering schools and communities to participate in the provision of DESIGN OF THE SECTOR PROGRAM education. This includes support of school commu- nities through training and transfer of resources. Lending instrument: The operation is called a Sec- MINED has decided to limit long-term TA to very tor Investment Program and the instrument is a tech- few key positions, e.g., financial management until nical assistance loan (TAL). As stated in the PAD, suitable staff can be trained and appointed into the the SIP approach "captures the essential principles regular civil service. on which the ESSP was developed; a sector-wide policy approach and close collaboration between the Government and donors in the preparation of the RATIONALE FOR THE program." SECTOR PROGRAM Consideration was given to the use of an adapt- able program loan approach (APL). This would have With 18 other donors and multiple NGOs imple- included basic education as a first phase, followed menting more than 150 projects in the sector, the by technical-vocational training, and higher edu- Government and donors saw the dire need to en- cation. However, it was not adopted because this hance the coordination and impact of projects in phasing "would have required defining the total in- the sector. The sector program was fundamentally vestment for the sub-sectors in the second phase and prepared to overcome weaknesses in the traditional committing IDA to a specific level of contribution project-based approach. The fragmentation in the in the investment program." Commitments to spe- use of resources and lack of coordination often led cific levels of funding for TVET and higher educa- to inefficiency. The MOE decided to adopt a sec- tion were considered premature. tor approach as a process for more effective 2UNDP, UNV, UNICEF, WFP, UNFPA, UN Womens Guild. IDA (World Bank) and ADB. Catholic Church, EU, etc. 118 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA management of funds. Through this integrated egy and the implementation framework agreed for SWAP approach, the Government would be better ESSP. able to increase its effectiveness in the use of do- mestic and external resources. The SWAP has also forced the transfer of implementation responsibili- DEFINITION OF THE SECTOR ties from the PIU (GEPE) to the line directorates of the ministry at the central, provincial, and dis- The sector as defined within ESSP includes primary trict levels. The resulting decentralization of and secondary general education, technical educa- resources and management responsibilities has also tion and vocational training, and higher education highlighted the need to strengthen the ministry at subsectors. The Ministry of Education is responsible all levels for more effective operations at a sustained for the three subsectors of primary and secondary level. This is being addressed in the context of the education, higher education, and technical educa- capacity building program. Success in effective tion vocational training (TEVT), although higher operations at all levels would enhance MINED's education has some autonomy in management. capacity to absorb increased resources from the Some ministries also run training programs inde- GOM budget and donors. This would be particu- pendently of MINED. The development of strate- larly relevant in the context of the HIPC debt relief gies for higher education is, however, the official initiative. responsibility of the Ministry of Education. It is done under the aegis of MINED, including preparation of TORs and budgets and task teams appointed by PRECONDITIONS the Minister of Education. With regard to TEVT, MINED coordinates its activities with other Minis- The preconditions for starting development of a sec- tries such as Labor and the private sector to avoid tor-wide approach were as follows: (1) macroeco- conflict in approaches and complementarity dur- nomic stability; (2) existence of a comprehensive ing implementation. sector development strategy, and (3) government commitment to a sector approach. Soon after the peace agreement sound macroeconomic policies led PROGRAM LEADERSHIP AND DONOR to unprecedented economic growth and fiscal sta- COORDINATION bility. Improved economic management and sta- bility was facilitated by the development of a The structure for implementing the ESSP is as comprehensive MTEF. With the MTEF as a back follows: drop GOM developed a coherent sector strategy, and subsequently a coordinated framework that F Program oversight and policy guidance: The included national and donor agencies for the imple- existing coordinating and advisory body of mentation of programs in the sector. This in turn MINED, the Conselho Consultivo do has reinforced MINED's ownership and control of Ministerio, will be responsible for policy the process. Although the capacity for a SWAP was guidance. The CC comprises the Minister, not in place at the inception, the government initi- the Vice-Minister, the Permanent Secretary, ated an aggressive capacity development program, and the heads of all national directorates and which helped create the minimum conditions for departments. completing the preparation of the program and c Organizational structure at the center: The starting implementation. Government's commit- guiding principle for implementing this ment to the process is evidenced by the decision to program is that the Government will imple- subsume all projects in the sector within the strat- ment the program with existing structures 119 ANNEX 8: MOZAMBIQUE EDUCATION CASE STUDY of the Ministry of Education. The overall * Theformal decreefor establishing this struc- structure for implementation proposed is ture was approved in August 1998. as follows: o Organizationalstructure in theprovinces and districts. MINED will phase in decentrali- (i) A Steering Committee (Comite Paritario zation gradually. Decentralization will start de Acompanhamento, COPA) will be with 3 districts out of 10 in the first year, the main vehicle for ensuring donor co- and expand as capacity is built in the re- ordination and for monitoring and gions and regulations for their operations evaluating implementation progress of are established. This process will include the the ESSP. The committee is headed by development of clear procedures for opera- the Minister of Education and its mem- tions and staff training. bers represent key ministries and ex- > Donor Coordination: Donor coordination is ternal partners. led by the Swedish Government. Regular (ii) A Technical Committee (TC) of the meetings are held to discuss common issues ministry will deal with technical issues. and to promote increased collaboration. A The TC will be headed by the Vice- code of conduct has been established to Minister and composed of national di- guide donor behavior. When necessary do- rectors, the chairs of the working nors meet in smaller groups to discuss spe- groups, and qualified individuals cific issues which may not be of interest to nominated by the Minister. The Execu- the whole community. tive Secretary will also be a member of the TC. No donors will be represented on this committee. PROGRAM DEVELOPMENT (iii) Working Groups (WGs) will be respon- sible for dealing with technical issues The key milestones in program development in- related to the various components, in- cluded the following: (i) The "National Education cluding the preparation of technical pa- Policy and Strategies for Implementation" (NEPS) pers, annual work plans, annual review which was prepared over a two-year period by the of implementation, and advice on Government with some support from external con- changes in the design or policies related sultants and financing approved by Parliament in to the various components. 1995, and (ii) The first draft of PEE (Plano Estrategico (iv) A Secretariat, composed of an Execu- de Educacao) was prepared, and was discussed at all tive Secretary and a few support staff, levels of the Ministry and with donors and civil so- will provide administrative services to ciety over the 1997/98 period. It was endorsed by the COPA, TC, and WGs in coordinat- donors in April 1998. During these consultations the ing and monitoring implementation of PEE was revised and expanded to include detailed the program, including day-to-day do- chapters on strategies for teacher training, gender, nor coordination. textbooks, institutional capacity, and school con- (v) A Financial Management Committee struction. Internal efficiency and cost-effectiveness (reporting to the TC) will review quar- of the system was also a major concern. MINED re- terly program management reports fined the strategy to ensure that plans for expand- produced by MINED's Department of ing the system did not prejudice quality. The Council Finance and Administration (DAF). of Ministers approved the strategy in 1998. Follow- The report will cover finances, outputs, ing endorsement of the PEE in 1998, the MOE started and procurement. preparation of the sector program (ESSP). It was rec- 120 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA ognized that the ESSP would be limited to basic edu- Because of gaps in the review of public expen- cation in the absence of a comprehensive sector ditures a separate study was needed on costs and fi- analysis of the costs and financing of education, in- nancing to analyze the education sector from the cluding estimates of returns to higher levels of edu- macro and micro perspectives. The study would fo- cation and an assessment of the external efficiency cus on demand and supply issues, access, quality, of the system. But the program would support the internal and external efficiency, equity, unit costs and development of the subsector. cost effectiveness, allocation of resources in the sec- tor and incidence of costs, and management of the system, including decentralization and community LEVEL OF SECTOR ANALYSIS participation. This would form the basis for refin- ing the strategy on basic education and for develop- A number of sector studies were carried out: Public ing detailed strategies for technical education and Expenditure Review (1997) by the World Bank, Fi- vocational training, and higher education. nancial Plan of the ESSP 1997-2001 (1998) by a WB The costs and financing study was not completed consultant, Teacher Education Reform Proposal prior to appraisal because the PER was considered (1998) by UNICEF and GOM, Reinforcing Institu- adequate for a "bridging operation," which was be- tional Capacityat MOE (1998) byMOE,World Bank ing proposed at the time instead of a SWAP. The and SIDA, National Policy on Textbooks and Learn- processing timetable and resources did not permit ing Materials (1998) by SIDA and MOE, the preparation of the costs and financing studywhen Mainstreaming Gender in the ESSP 1997-2001 it was decided that a SWAP would be more appro- (1998) by UNICEF and MOE, Financial Manage- priate. At the same time, the political momentum ment Review (1998) by the World Bank. In addi- was there to move forward. tion, a number of sector papers were prepared by some donors and MOE on curriculum development, human resource development, and poverty. These INSTRUMENTS FOR AGREEMENTS studies were revised and built on by the various working groups as the program was finalized. The instruments included aide memoires from the The economic sector work that was done dur- joint MOE-donor meetings; the joint review meet- ing preparation was more like a public expenditure ing of the PEE in April 1997, the program pre-ap- review, which was used as a basis for projecting the praisal held in September 1997 and the first Joint future growth of the sector on some assumed unit Annual Review held in May 1998. Consensus costs. Although the study made some policy recom- was reached on the process and steps to follow, and mendations, the analytical underpinnings of the pro- a code of conduct was developed and agreed to posed strategy were not clear. The study also did not by all. deal in sufficient depth with issues related to alloca- tion of resources among and within subsectors, or with the internal and operational efficiency of the INSTITUTIONAL CAPACITY system. Gender, socioeconomic, and geographic in- equities in the provision and in educational attain- Individual assessments were carried out by external ment were also not fully addressed. The costs of assistance, and MOE set up a task force to prepare construction were also very high, and the proposed the institutional assessment. Three key sector stud- solutions met with stiff resistance from the govern- ies were prepared, including one assessment of the ment because NGOs were permitted to compete for financial management system. construction contracts as private firms, and because A systematic approach to the institutional de- the school designs were considered inappropriate. velopment of MINED was initiated in 1995, with 121 ANNEX 8: MOZAMBIQUE EDUCATION CASE STUDY assistance from various donors, to strengthen the Answering these two questions, the team will sys- management capacity of the Ministry especially in tematically identify all the organizations, and the a number of critical areas. These initiatives were organizational units, that are to be involved in the important following the war, which disrupted ac- implementation of the proposed investment tivities in most parts of the country, and given the program. Once these are identified, the team will generally limited number of qualified people in the examine the five factors indicated above with re- country. This effort has been supported by Bank spect to each and every organization and organi- operations in Mozambique, especially the Capac- zational unit individually. This examination will ity Building Project, which is supporting second- help determine institutional weaknesses and ca- ary and higher education to provide a pool of pacity gaps. qualified people to manage the civil service and the Four types of alternative capacity building mea- private sector. This is especially important for sures will then be considered in each case where a MINED, which needs to manage an expanding pro- capacity gap is identified: gram in a rapidly growing economy, and which is also gradually decentralizing management of the > To change practices, ways of doing things sector to the provinces and districts to improve ef- and procedures, where such a change can ficiency in the delivery of services. The policies and improve the capacity of the organization or measures introduced over this period were based unit involved, without having to allocate it on a global assessment of current management more resources. practices and capability, including operational pro- .s. To allocate, or reallocate, financial and hu- cedures and methods. This assessment, as well as man resources for the performance of cer- the development and implementation of the pro- tain activities, where the gaps are considered gram was conducted using a participatory ap- to be the result of inadequate resources. proach. This has resulted in ownership and an > To spread certain activities over a longer pe- identification with the objectives and activities by riod of time, or to reduce the scope of cer- staff at all levels in MINED. MINED plans to build tain development objectives, where on this foundation by conducting a more thorough additional capacity is required but cannot analysis of each administrative unit of the Minis- be built immediately, or during the currently try at the central, provincial, and district levels, as scheduled implementation period. a basis for defining the capacity needed in each * To follow a certain mix of these three alter- section and at each level for efficient delivery of natives. quality education. The methodology to be used in performing The institutional assessment team will consist this institutional assessment is based on an opera- of members of the working group on capacity build- tional definition of capacity. Applying this defini- ing and a long-term consultant from ASDI, sup- tion, the capacity of all the organizations involved ported by a Bank Team. The officials and the in the implementation of the proposed program consultant will be trained to apply the methodol- will be analyzed by focusing on organization, lead- ogy. By the end of this assessment, they will be able ership, financial resources, material resources, hu- to use the methodology to carry out similar assess- man resources, and work practices. The assessment ments independently. The managers of each orga- team will focus first on the question "What needs nization and unit assessed will be thoroughly briefed to be done in order to implement the program?" on the objectives of the capacity building initia- or "For what is capacity required?" It will then tive, as well as the methodology, and will take an determine "Who needs to do it?" or "Whose ca- active part in the assessment and identification of pacity within the education sector is in question?" solutions. 122 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA STAKEHOLDER CONSULTATION zational structure of the MOE and support to de- centralization; development of MOE policy and plan- During the preparation of the PEE and of the ESSP ning; building MOE financial management; and program, the MOE organized wide-ranging discus- conduct of monitoring and evaluation. (4) TVET: sions at central, provincial, district, school, and com- production of a subsector strategy and financing its munity levels. As stated in the PAD, "The implementation. (PAD, Annex 2 provides a detailed Government's Strategic Plan was developed with the description of the program.) participation of a full range of stakeholders includ- ing parents, local communities, employers, NGOs and religious organizations. This was achieved Organization and Management through: (a) bringing teachers and staff into the decision-making process through various working The guiding principle for implementing the program groups, (b) increasing representation of actors at the is that the Government will implement the program provincial, district and school levels in the planning within existing structures of the MOE (PAD: 14). process, (c) strengthening pedagogical support zones Also see previous discussion of this subject. and training school directors to interact more effec- tively with communities, and (d) holding consulta- tive sessions with civil society" (PAD, pp. 30-31). Financing Overall the ESSP program is perceived to have been "prepared and owned by the Mozambicans." The estimated cost of the ESSP including contin- gencies is US$717.2 million. As a comprehensive plan for the sector, the ESSP includes the costs of salaries THE SECTOR PROGRAM (US$293) and other recurrent costs including op- eration and maintenance. Of total costs, the Gov- Objectives and Strategy ernment would finance an estimated US$ 444.6 million, NGOs US$ 30.0 million, communities (in The objective of the ESSP is to achieve increased and kind or in cash) US$ 5.0 million, IDA US$ 71 mil- equitable access to higher quality education through lion, and other donors US$ 118.8 million. improvement in the management of education in order to promote social and economic development. Modus Operandi Content Monitoring and evaluation arrangements: MINED will monitor and evaluate the program within the The ESSP includes four components: (1) Quality of structure setup for implementation and using de- primary education: training and pedagogical sup- tailed terms of reference for key units within this port for teachers, curriculum revision, increased structure. Monitoring and outcome indicators will supply of learning materials, strengthening of stu- allow MINED to measure progress and will form the dent assessment and examinations, direct grant sup- basis for joint supervision with other donors. Each port to schools, and training of school directors. (2) unit involved with implementation will develop in- Access to basic education: building and rehabilita- struments for monitoring its respective component, tion of schools; promotion of girls' education; de- while the Planning Unit and the DAF will consoli- velopment of non-formal education; and pilot date and analyze statistical, financial, and physical programs for special education. (3) Strengthening data on the rate of implementation. A system will MOE Institutional Capacity: strengthened organi- be introduced to provide information on output 123 ANNEX 8: MOZAMBIQUE EDUCATION CASE STUDY indicators such as expenditures, units built, and num- (4) An increase in enrollment in the schools and ber of teachers trained. Capacity will be built in the districts where classrooms are built, equiva- provinces for collecting monitoring data. The Ex- lent to about 75% of new capacity created. ecutive Secretary (responsible to the Technical Com- (5) Implementation of at least 80% of the work mittee and CC) will synthesize the results. The donor program for each year measured by the group will coordinate and manage donor-related physical targets and budget spent for pro- matters, such as the preparation of statements of gram and routine activities. donor contributions, to minimize MINED's time- (6) Achievement of the agreed rate of decen- consuming task of dealing with individual donors. tralization of management to the provinces Formalized supervision will take place twice a year and districts as defined in the Program to review progress in implementation. Government Implementation Manual. and donors will jointly prepare the terms of refer- ence and participate in the mission. The Government In addition to these six indicators agreed to by and each of the provinces will prepare annual progress all donors, consensus was reached during the first reports that not only assess overall progress but also annual meeting to expand the indicators to include: highlight components or districts with bottlenecks (i) increases in girls' enrollment and retention, (ii) or weak performance. MINED's information-gath- improvement in learning outcomes (EFA indicator ering activities will be the basis of the reporting re- #15), and (iii) improvement in completion rates at quirements for the joint annual review meetings with all levels. Independent consultants will also carry out donors. This review will be carried out immediately technical audits of the program starting in the sec- following MINED's annual meeting with provincial ond year to assess the quality of implementation and and district directors. The first annual review was held make recommendations for improvement (PAD, p. in May 1999. A midterm evaluation of the program 19). Procurement under the program will be decen- will be held no later than 30 months after program tralized to the provinces, although this process is still effectiveness, in accordance with terms of reference at an initial stage. The center will carry out all ICB agreed upon by MINED and the donor community. procurement and consultant selection under the pro- Monitoring indicators: As part of the ESSP a pro- gram, coordinate all activities at the provincial level, gram monitoring reporting system (PMR) will be and assist the provinces with standard bid docu- developed to monitor education outcomes, finan- ments, construction plans, and technical advice. To cial indicator and link expenditures, and outputs and strengthen the center's performance, an experienced schedule of implementation, including procurement, executive secretary has been appointed, staff from for each component. Currently the following indi- GEPE (the former project implementation unit) have cators have been identified: been incorporated into MINED central functions, and an advanced procurement course was held in (1) Increased proportion of students passing key March 1999 in Maputo. primary and secondary examinations: At the provincial level, only three pilot provinces (i) Grade 5 from 54% to 75% will manage their own procurement in the first year (ii) Grade 7 from 37% to 60% of the program. Each of the provinces will establish (iii) Grade 10 from 33% to 55% program implementation arrangements based in the (2) A reduction in the average repetition and provincial MINED offices, supported through ca- dropout rates by half for primary and lower pacity building. The provincial MINED office will secondary. implement the procurement of small works, furni- (3) An increase in gross enrollment rates (i) ture, and educational materials using National Com- Grades 1-5 from 67% to 86%; and (ii) petitive Bidding (NCB) and will assist rural districts Grades 6-7 from 15% to 30%. to utilize community participation in school con- 124 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA struction. The MINED offices will be encouraged to GOM procurement regulations maybe used for NCB delegate management and supervision of works to contracts, provided that IDA procurement regula- more experienced local consulting firms. A detailed tions would prevail in case of conflict. list of actions to be taken by central and provincial MINED offices prior to program implementation have been agreed on. Financing Within the five-year ESSP program of US$717 mil- Financial Monitoring lion, IDA will maintain a presence in strategic com- ponents. The financing plan for the program was MINED's Directorate of Administration and Finance drafted during the joint donor assessment mission (DAF) will be responsible for overall management in May 1998 and further refined during appraisal in and reporting of the principal financial resources for late 1998. By appraisal a total of about US$85 mil- the ESSP. Every quarter, the Financial Management lion had been committed to ESSP by various donors Committee (reporting to the Technical Committee) to support ongoing activities that were part of the will review DAF's program management report. In- program. Approximately US$105 million was also dependent auditors acceptable to IDA will audit pro- expected to be provided by donors over the five-year gram accounts annually and provide a management program period. The schedule for agreement on new letter that recommends improvements to the finan- funds would follow the natural cycles of the various cial management system. In the medium to long agencies. A number of donors also (e.g., Denmark, term, the Government proposes to introduce a new the Netherlands, Sweden, Ireland, and the United financial management system (FMS), as part of the Kingdom/DFID) planned to provide part of their overall civil service reform program. funding for the program through direct budgetary support. Some donors even tied all new funding to agreement on budgetary support by at least a core Harmonization of Donors' Procurement group of donors. About US$70 million was expected Procedures to be provided through this means. The Bank was the donor of last resort, but became involved in a Harmonization of procurement and disbursement core strategic program because of the uncertainty procedures is feasible under the Program and has over when (and perhaps whether) new funding been the subject of a detailed study by IDA. It is ex- would materialize from several key donors. The nor- pected that some of the donors will agree on com- mal approval cycles for the various donors meant mon thresholds for procurement under NCB; the that commitment of new funding would be drawn use of post-review and of reporting formats. Do- out over two or three years. Conditioning assistance nors may also agree on the use of standard docu- on budget support added more fragility to the equa- ments and procedures for advertising, evaluating, and tion. Budget support was entirely new. No one knew awarding the contracts. IDA procedures and docu- how to do it. The Bank therefore agreed to partici- mentation will be followed for all ICB procurement. pate in the financing of several components.5 Core i In-service teacher training (US$6 million), pedagogical support for teachers through Zips (US$6.1 million), curriculum transformation (US$1.0 million), learning materials (US$6.4 million), examinations (US$0.30 million), direct support to schools (US$4.9 million), training of school directors (US$1.0 million), school construction and rehabilitation (US$31.8 million), gender initiatives (US$5 million), and capacity building (US$8.3 million), for a total of US$70.8 million. A small amount of funds will also be allocated for developing strategies for further development of technical education and vocational training. 125 ANNEX 8: MOZAMBIQUE EDUCATION CASE STUDY financing by the Bank was designed to ensure con- were agreed to as outlined under the previous sec- tinued financing of the program as a whole pending tion on monitoring. It was further agreed that no the release of other donor funding. There is agree- new project would be initiated outside the agreed ment between the Government and donors that framework. More specifically, several process-related nothing outside the strategic framework will be fi- conditions are incl uded, such as joint annual pro- nanced during the period of program implementa- gram reviews in May, submission of annual work tion. The Bank disburses on the basis of incurred program and budget byOctober, submission of semi- eligible expenditures included in the annual revised annual progress reports including outcome and per- targets (annual work plans) through the Special formance indicators. Other conditions are related to Account. the preparation of specific plans (e.g., community involvement in establishing and running schools, policy and plan for privatization of textbook publi- Administration, Accounting, Financial cation, plan for improvement of internal efficiency, Management, and Auditing Functions plan for management of direct grants for schools, and plan for improving time on task in schools). As MINED's Directorate of Administration and Finance the program is integrated into the Ministry and later, (DAF) will be responsible for overall management the annual work plans discussed widely, it guaran- and reporting of the principal financial resources for tees consistency; and any issue that comes up should the ESSP. The Government will keep the funds from be resolved during this process. IDA and each other donor in separate accounts but will move toward common procurement, financial management, and auditing procedures acceptable to IMPLEMENTATION OF THE SECTOR PROGRAM all partners. Financial statements will show ESSP basket expenditures as well as the source of the funds. Implementation Experience Donor agencies support the gradual transfer of funds to MINED through budget support as its financial The IDA Credit became effective on August 3, 1999 management capacities improve. In the medium to and implementation is still in its early stages. In the long term, the Government proposes to introduce a first year of the ESSP the Government focused on new financial management system (FMS), as part setting up the financial and institutional arrange- of the overall civil service reform program. ments for the ESSP. Preparation of the comprehen- sive provincial plans were the main focus during this period. The new organizational structure has shown Conditionality to be an efficient structure for implementing the program as evidenced by the following: (i) coordi- The program was designed to be consistent with the nation among national directors has increased, (ii) Government's Medium Term Expenditure Frame- integration of the program in MINED has improved, work and the targets set out under the ESSP. In the (iii) transparency in the use of donor funds has in- Government's Letter of Sector Policy and the attached creased, and (iv) the government is becoming in- policy matrix the detailed qualitative and financial creasingly proactive in managing implementation indicators and Government conditions are stipulated, because of the realization that it is accountable for including increasing government budget for educa- results. tion from 18.2% in 1998 to 21% in 2003 (from 3.5% Commitments of some donor funds were linked to about 5% of GDP). In addition the share of basic to budget support, (consistent with the spirit of ESSP) education will be increased by up to 2% of GNP in with the expectation that this would be easy to ar- the same period. On the qualitative side the targets range. This turned out not to be the case. A joint- 126 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA donor mission for the education sector assessed the * Agreement of so many (18) donors on a scope for using this approach in September, and rec- common, single program. ommended against it because of capacity concerns o Harmonization of monitoring & evaluation at MINED and MPE Subsequently, the Swedish, Irish, procedures, including common indicators, and Dutch aid agencies proposed the pooling of common reporting, joint annual reviews, funds at the MINED level until the concerns regard- etc. ing the flow of funds through the MPF were ad- o "Institutionalizing" the program, by mov- dressed. The Bank decided to join this group, and ing the locus of control from separate and the mechanism for doing this is now being explored. isolated PIUs into the main offices and de- The joint financial management mission in which partments of the MOE. consultants from Irish Aid, SIDA, Dfid, CIDA, Finnida, and the World Bank participated, and which was led by MOE, is a good example of the new col- Main Problems (or lack of achievements) laboration among partners. Design Phase There has been little or no disagreement over strategy. Donors have been willing to use the imple- There were no major disagreements or misunder- mentation designs agreed by the MINED and col- standing during the design phase. There was some laboration is strong at this level. concern about the ability of the government to train and finance the required number of teachers required for expansion. When this was analyzed in detail, es- Main Achievements pecially in light of the much lower population fig- ures from the recent census and plans to improve Although tangible education results can only be internal efficiency, this turned out to be less of an measured over the long term, there is clear evidence issue. There were similar concerns about other is- that the ESSP has proven itself to be an efficient ve- sues, but these were also resolved following further hicle for moving the program forward; it has analysis. strengthened government ownership, it has empow- During implementation: There have been no ered national directorates and ministry staff, and the unexpected problems during the implementation program has been integrated into the ministry in- period. Concerns and issues have been expressed creasing transparency and ensuring increased effec- early on and have been discussed and resolved in tiveness in the implementation of agreed activities. the spirit of collaboration and mutual professional The reinforcement of the authority of national di- respect. rectors has given them the authority over externally financed activities, including IDA-funded activities. While it was agreed at the first annual review that OBSERVATIONS AND POSSIBLE LESSONS the move toward common procedures is a longer- term effort, a joint framework-joint collaboration The following lessons can be drawn from the devel- in assessing needs and requirements to move the opment of the ESSP Sector Program in education: process forward for establishing common financial and procurement procedures is already under way. o ConditionsfortheDevelopmentofaSWAP: This rationalization is further exemplified in the joint (1) The experience with the sector program work and missions being undertaken. in Mozambique shows the importance The main factor explaining the success of the of: (i) starting with a Government-pre- SWAP is government ownership and strong govern- pared strategy in which donors play a ment leadership. supporting role; (ii) government tak- 127 ANNEX 8: MOZAMBIQUE EDUCATION CASE STUDY ing the leadership in coordinating the > Common Procedures under a SWAP: donors; (iii) setting up clear institu- (1) There is a need to revise government's tional arrangements and an organiza- procurement procedures to ensure that tion structure for collaboration within it satisfies donor demands for efficiency, the ministry and with and among do- competition and transparency in the nors at the very beginning, especially award of contracts. This would obviate during the preparation of the policy and the need for the tortuous attempt to har- strategy, as this in turn sets the stage for monize donor policies. the future; and (iv) building consensus (2) Donors need to understand better and at all levels of government and related be involved with the evolution of institutions, as well as among stakehold- changes in public financial manage- ers such as civil society, NGOs, and pri- ment, especially relating to changes in vate institutions. the budget law to help design systems (2) The initial step for launching a sector that will satisfy the needs for transpar- program is a coherent strategy under ency and accountability. which all stakeholders will operate. * Precondition and When Not to Do a SWAP The move toward budget support and (1) The starting point of a SWAP should be common procedures should not be based on Government desire and com- an objective by itself, but a natural mitment to move toward an integrated development toward building national strategy and sector program. If govern- capacity. ment commitment is not there, the coa- . Benefits of a SWAP lition of donors would be fragile and (1) A Government-led SWAP focuses atten- eventually break down at some point. tion on country priorities instead of (2) A clearly costed program consistent supply-driven agendas. with a Medium-Term Expenditure (2) A SWAP reinforces the Government's Framework would constitute the major control over funds, especially external condition for initiating a SWAP process. financing, minimizing the margin for * Risks individual donor negotiations and do- (1) Some of the risks concern the enormous nor-driven agendas, thereby increasing amount of time spent on donor coor- the effectiveness in policy execution dination with limited concrete output. (funds spent on activities for which they This is especially the case if there is in- are intended and in consistency with sistence on budget support and the use national development objectives and of common procedures at the inception priorities). of the program. Capacity building (3) A SWAP increases Government ac- should be seen as one of the objectives countability as its authority over activi- of the SWAP. ties and funding increases, thereby, + Sector Performance increasing stakes and commitment. (1) A set of indicators should be adopted (4) A SWAP eases the administrative bur- on sector performance. A Financial den of Government in dealing with Committee should be established to multiple different donors and systems monitor performance and match ex- (5) A SWAP demands the development of penditures with activities. These data capacity and national systems, instead should be included in a comprehensive of individual and parallel systems. monitoring and evaluation mechanism. 128 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA List of "dos" and "don'ts" for SWAP design and (D) Don't: The ultimate objective is not harmo- implementation. nization of donor procedures, but develop- ment of good government systems. (A) Do: It is important to agree in advance on (E) Do: Financing the core program - does this ground rules for all parties. It is difficult to approach reduce the risk and uncertainty keep a diverse group of donors together. that some donors may not contribute? No, There will be disagreements, which means it means that the Government will be able that procedures need to be agreed in ad- to deliver its education services with a view vance on how to handle disagreements. to ensuring long term improvements. Government needs to take the lead. (F) Do: Joint annual reviews-what do they (B) Do: Specifically, the role and authority of need to be successful? Government needs the "lead donor" should be clarified in ad- to take the lead, otherwise the annual re- vance. view runs the risk of representing individual (C) Do: The sector program depends to an ex- donor agendas. traordinary extent on the collaborative re- (G) Do: Monitoring indicators-how should lations established between the parties, they be improved? With the development that-in turn-depends on openness. It of internal capacity and systems. It is im- means, inter alia, the Government has to portant to note that monitoring indicators be committed to a process of examining are not only statistical, but the overall per- itself as well as donors putting aside dis- formance of the sector can be reinforced agreements. through adequate institutional setup. 129 ANNEX 8: MOZAMBIQUE EDUCATION CASE STUDY TABLE 1 1786 - Mozambique, Gen. Educ. Sec. Exp. Program Project Status Report Date: 5/20/99 Region:tt000 \AFR C:ouitry: MOZAMBIQUE Sector: EP Lending lstr: TAL iPrg ObjCat:; PA 0iEACaCt: C PTI? Y NGO? N Resettlement? N Agree LICIG Rev'd Currency Prod~ ~ Signing, Efcive SupI Pr *Typ No. OiAt Amit Indicatorl Line Dat aeI IDA 31720 51.10 (SDR) PE 3/4/99 TotalOrigin mIount (SDR): 51.10 TotalReiseAount (SDR): 0.00 COIANIG INFRMTIO Agency Bo~~~~~~~~~~~~~Ard Am t ($)Cret Amut(M Total ~~~~~0.00 0.00 Gurate Tye uaranteeAmottnt ($M) Thsf orm is par of:gw00000;f00000fAASt0000000XSV Initial: Summary0000XiAfV0000\S00000000000 fi;00000ffff ffft0000 Aide-memoire Mission End Date: This Form PSR Date: 5/20/99 SUPERVI:S :: : e i:ON ; (\: )L FQf Staf Tota Stff Fi As of, Current FY- Planned12.60 38.48 current FY - Actual26.38 89.97 1.13 4.43 preceding PY 0.00 0.00 0.00 0.00 Total Actual ~~~26.38 89.97 1.13 4.43 UPI N Fol l ow-up Metter o: 000Wission Membe Speciaization Mission 130 ANNEX 9 Zambia Education Case Study1 Basic Education Subsector Investment Program (BESSIP) BACKGROUND from external donors has been fragmented. Despite considerable external support, Zambia's education Reflecting economic deterioration, Zambia's educa- indicators have stagnated. The trend suggested the tion system also deteriorated significantly during the need for a different approach so as to make a bigger 1980s. A new administration with a different eco- impact on solving pressing educational issues. Al- nomic philosophy came into power in 1991, and em- ready in Zambia two other sector-wide approaches barked on the process of articulating its policies in were under implementation, in agriculture and a number of sectors, including education. This led health. The government and donor community were eventually to the issuance of a Government policy familiar with the approach and its potential ben- document, "Educating Our Future: National Policy efits. It was only natural, then, that the Government on Education." The Policy was adopted by Parlia- and all major donors decided to try a sector-wide ment in 1996. The document identifies the prob- approach. lems facing the sector, identifies targets for 2005 and 2015, and highlights a strategy for moving forward. At the time, the education sector was beset with THE BESSIP PROGRAM myriad problems: Two of the key issues are stagnat- ing enrollment rates and poor learning outcomes. The Basic Education Sub-sector Investment Program These problems leave the low share of government (BESSIP) is the national program of basic educa- budget allocated to education and a misallocation tion of the Government, developed between 1996- of education within to tertiary education-in large 98. The two main objectives are to increase part for student personal welfare. The effectiveness enrollment and to improve learning outcomes. Gross of teaching in basic education is compromised by enrollment ratios are planned to increase from 84% limited instructional times, inappropriate language at present to 100% by 2005, and net enrollment ra- of instruction in rural areas, inadequately prepared tios to 90%. Improved learning outcomes are also and motivated teachers, lack of instructional mate- the focus and will be measured by national assess- rials, the poor state of classrooms, and inadequate ments. The Program includes eight components: in- programs to help disadvantaged children. Support structional materials, teacher development and I This case study is based on interviews with the two Task Team Leaders, Mr. Paud Murphy and Mr. Bruce Jones, and the following two documents: IDA Project Appraisal Document, March 5, 1999, No. 19008ZA, and Barbara Chilangwa, "Issues, Experiences, Challenges and Lessons in the Process of Establishing the Zambian Basic Education Sub-Sector Investment Programme (BESSIP)'" 131 ANNEX 9: ZAMBIA EDUCATION CASE STUDY deployment, school health and nutrition, equity, in- mentation, in agriculture and health. The govern- frastructure, curriculum development, capacity ment and donor community were familiar with the building and decentralization, and BESSIP program approach and its potential benefits. It was only natu- management. ral, then, that government and all major donors de- cided to try a sector-wide approach involving a common sector policy framework and medium term SWAP DESIGN investment program as well as promoting Govern- ment capacity and leadership. Lending instrument: BESSIP is supported by an adapt- SWAP characteristics: The coverage of the pro- able program loan (APL). The overall program is gram is not sector-wide, but it nevertheless has most five and a half years. The first phase is from January of the characteristics of a SWAP. It stems from an 1999 to June 2002, to which IDA is contributing overall policy on education and training, "Educat- US$40 million. A second phase is expected from July ing Our Future-1996" It is based on a long-term 2001 to June 2006 including US$60 million in IDA vision and program for the top priority subsector, financing. Both phases focus on basic education, with basic education, on which the Government and all more emphasis on capacity building in the first phase major donors agree. There is an agreed expenditure and pilot measures to increase enrollments and learn- framework for the subsector program. Local stake- ing outcomes for disadvantaged groups. Key trig- holders were in charge of development of the pro- gers for starting the second phase are: (1) at least gram, particularly after a new Minister of Education 20.5% of government discretionary budget (the took over (see below). All the main donors have portion of the budget available for annual alloca- agreed to finance a share of the costs of the program. tion through the budgetary process, but excluding Finally, efforts have been made to use normal Gov- the portion of the budget committed to debt service ernment capacity and processes and adopt common and pensions as a consequence of budgetary deci- procedures and reporting as far as possible to mini- sions of earlier years) allocated to the Ministry of mize administrative burdens on the Government. Education and maintenance of at least 60% share of Preconditions: Several preconditions were con- the MOE budget for primary schools, (2) share of sidered to be essential before embarking on a modi- trained teachers increased in rural schools; (3) con- fied sector-wide approach. First was relative struction of 2000 classrooms; (4) bursary scheme in macroeconomic stability, so that resource allocations place for poor children; (5) completion and pub- could be planned with some degree of certainty. (Un- lishing of results of a first national assessment of fortunately, macroeconomic stability has not yet been learning achievements; and (6) district education achieved in Zambia. The rate of inflation has recently boards established and functioning in 60% of dis- been about 30%.) Second, a conceptual framework tricts - as well as preparation of the second phase. existed for the whole sector in the form of the 1996 Rationale for the SWAP: Zambia has consider- National Education Policy. Third, most donors sup- able experience with external financing in education. ported the development of a broad program ap- About 14 external agencies have provided support proach in view of frustrations with success of to the education sector. Much of the support has been previous projects. Finally, there was strong Govern- fragmented, with each project having its own insti- ment leadership-not at the start of the process but tutional arrangements. Despite considerable exter- that emerged and allowed the program approach to nal support, Zambia's education indicators have flourish. stagnated. The trend suggested the need for a differ- Definition of the sector: Development of the pro- ent approach so as to make a bigger impact on solv- gram went through several stages of reduction in ing pressing educational issues. Already in Zambia scope to achieve a final definition of the "sector," or two other sector-wide approaches were under imple- in this case, "sub-sector." Initially an attempt was 132 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA made at developing a comprehensive Education Sec- cern over the perceived "dominant role of the World tor Investment Program (ESIP), coordinated by an Bank" During the past year, this concern diminished ESIP Secretariat. Higher education was excluded as MOE displayed increased ownership of the pro- from the beginning on the basis that it was an area gram, and as three of the bilaterals (DflD, USAID, of lower priority for new investment, than basic edu- and NORAD) added education specialists to their cation and training. ESIP still included four minis- Lusaka offices specifically for BESSIP, enabling them tries, (i) the Ministry of Education; (ii) Science to play a greater role in the dialogue. Close donor Technology and Vocational Training; (iii) Youth, collaboration is evident in the fact that four other Sport and Child Development, and (iv) Commu- donors served as observers (and often participated nity Development and Social Services.) In Septem- in discussions) at negotiations of the IDA Credit. ber 1997 the Government agreed with donors for However, at about the time of negotiations the Bel- its agenda in the education and training sector to be gian authorities gave Zambia funds for teacher train- supported by two financing packages, one for basic ing without any discussion in advance among the education (BESSIP) and another for training donors. (TSSIP). BESSIP is led by the Ministry of Educa- Program development: The first stage in the de- tion, and the great majority of its activities are within velopment of the program was the efforts at devel- MOE. However, a bursaries subcomponent will be opment of the ESIP starting in 1994 and the administered through the Public Welfare Assistance adoption of the National Policy on Education in Scheme of MCDSS, and a Microprojects Unit out- 1996. During this process some 17 studies were gen- side MOE (attached to the Ministry of Finance and erated on specific issues, of which 11 concerned basic Economic Development) will continue to adminis- education. These reports generated discussions and ter community-implemented school construction fostered mutual understanding about the issues and activities. consensus on the interventions required. All donors Program leadership: After the former Vice Presi- were broadly comfortable with the directions in the dent became Minister of Education in December Policy. However, the Policy needed more specificity 1997, he convened a conference with donors in Feb- on timing and volumes. These were generated ruary 1998 and gave his clear vision and authority through Bank missions on which donors were in- for the development of a sector program. This was a vited to participate. The culmination was a joint seminal event in the development of BESSIP because donor appraisal mission in September 1998, which it gave potential donors a clear impression of gov- produced a Joint Appraisal Report. By the conclu- ernment leadership of the process and clarity about sion of the appraisal process two additional impor- program goals and content. tant documents had been produced by the Donor coordination: On the donor side, the Bank Government, partly with Bank assistance: The Pro- had been financing, through a Japanese grant, the gram Implementation Plan (PIP) and the "State- studies under the ESIP. Donor coordination for ment on Education Policy Implementation during BESSIP was achieved through an informal donors 1999-2002."2 Basically throughout the process no group, the "Consultative Forum" for meetings con- major disagreements emerged between the Govern- vened periodically by the ESIP Secretariat. Since then, ment and donors, or among the donors about the an electronic forum of BESSIP donors has been es- policy aspects of the Program. The Ministry of Edu- tablished with continuous communications through cation did modify its position to allow more com- e-mail. In early stages some donors expressed con- munity demand-driven construction administered 2 Officially submitted by the Government to the Bank and appearing as Annex 11 of the Project Appraisal Document. All partners had a chance to comment. 133 ANNEX 9: ZAMBIA EDUCATION CASE STUDY by the Microprojects Unit under the program. Con- Instruments for agreements: The Government siderable discussion took place, however, concern- produced the basic national education policy docu- ing implementation and financing under the mentwithwhichdonorsbroadlyagreed.In 1996the proposed SWAP. Agreements were reached relatively donors signed a Joint Statement expressing their easily to coordinate and use common procedures/ interest in supporting education in Zambia through reports on program planning and review, budget- a sectoral approach, but also expressing concern over ing and performance monitoring, and progress re- the low share of the Government budget devoted to porting. Most difficult was harmonizing approaches the education sector. In 1998 four bilateral donors on procurement, contract administration, finance, established a preparatory fund to support the initial and accounting. The amount and nature of insti- activities for BESSIP. The joint appraisal (in which tutional capacity building needed before investment 17 donors participated!) produced a common, joint was always a major topic. Another was the modali- appraisal report. A sample "code of conduct" pre- ties of financial assistance. In particular so much pared by the European Union was circulated. While confusion reigned about "basket funding" that the not officially agreed, it provides a generally accepted term was banned. The PAD presents a typology that statement of principles. Finally, all parties have agreed was developed to clarify the various methods of pro- to the Program Implementation Plan that was re- viding financing under BESSIP. (See Financing, viewed at appraisal and subsequently revised. below.) However, where one donor was active and Institutional capacity: No formal instruments heavily involved in certain components (e.g., the were used to assess the capacity of the Government Danish program for teacher training), the Bank to implement the program, and a comprehensive pro- tended not to enter into a deep dialogue and glossed fessional analysis was not undertaken. In 1997, a team over differences. of officials from the Management Development Di- Level ofsector analysis: The BESSIP program was vision of the Cabinet Office and the Ministry of not preceded by any formal education sector work. Education prepared a Report on the Restructuring The ESIP had produced about nine documents that of the Ministry of Education. The Restructuring Re- provided background information on basic educa- port assigns the responsibilities of District Educa- tion. In November 1996 a consultant prepared an tion Offices to District Education Boards and District Education and Training Sector Expenditure Review Education Standards Officers. At the Headquarters, that also proved to be useful background informa- the Deputy Permanent Secretary posts are abolished, tion. In addition, more than ten studies on specific and there are six units whose heads report directly aspects of basic education were financed through a to the Permanent Secretary: Planning and Informa- PHRD grant managed by the BESSIP Secretariat. tion; Human Resources and Adminstration; Stan- Topics included equity, health and nutrition, instruc- dards and Curriculum Development; Teacher tional materials, teacher development, construction, Education; Accounts; and Procurement. This restruc- and examinations. However, the Secretariat gener- turing was intended to support decentralization, and ally did not have the capacity to manage quality in otherwise enhance the capacity of the Ministry to analytical work and the work tended to be almost meet its mandate. However, until now the reforms exclusively by educationists. The results were gener- have not been introduced because of lack of money ally disappointing. At one stage of the review pro- to compensate those persons whose jobs would be cess, for example, criticism was voiced in the Bank abolished. Considerable attention was devoted to that the Program did not have a specific vision for financial management and procurement capacity, and how to proceed to the ultimate objective of univer- specialists in these fields participated in the appraisal. sal primary education. Bank missions had to make Stakeholder consultation: Early in the process of up for the lack of analytical rigor in the background developing the program some stakeholder consul- studies. tation took place in the preparation and discussion 134 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA of the various studies under the ESIP. The 1996 Na- donors so that it can be adaptable to support pro- tional Policy on Education in fact calls for the Gov- vided by other donors. ernment to work closely with NGOs, local Financialflows and disbursements: The BESSIP communities, donors, and other stakeholders in the Preparatory Fund received funds into a common provision of education. However, observers of the account ("pooling") by several donors, including the BESSIP process stated that actually there was only U.K., Dutch, Irish, and Norwegian donor agencies. limited participation by teachers' unions, NGOs, and This became the model that Government wished to the community school sector in the process of pro- use for the full program implementation. It was rec- gram development. Those occasions that were meant ognized as the ideal method during the joint ap- to foster exchanges of ideas tended to be dominated praisal, but was not foreseen as being acceptable to by donors. most donors because of weaknesses in existing ca- Financing: The first phase of BESSIP is expected pacity for financial management. Instead, BESSIP to cost US$340 million, of which the Government is was explicitly designed to allow flexibility in the chan- expected to finance about half, IDA 12%, and other neling of funds by donors. The following external donors 38%, of which about half would be new com- financing modalities are recognized: mitments and the rest ongoing assistance programs. Risks and dangers: Given the broad subsector IDA support is structured in such as way as to en- objectives that the Program seeks to achieve, staff able IDA funds to be devoted to any of the compo- feel that the risks of giving important responsibili- nents. About three-fourths of the credit proceeds are ties to mainstream MOE units are outweighed by allocated to specific categories of new expenditure, the potential benefits of this approach. and one-fourth was left unallocated so as to flexibly Conditionality: The IDA Credit Agreement re- meet needs for which the Government is currently fers to the letter from the Minister of Finance dated seeking grant aid, but not all of which may materi- February 15, 1999, with attachments, describing "the alize. Initially funds are likely to finance schools, text- Program"' Article V of the Credit Agreement gives books, and vehicles and other equipment to support IDA the right to suspend disbursements in the event decentralization. that "a situation shall have arisen which shall make Procurement: Procurement under the IDA Credit it improbable that the Program or a significant part will be carried out along traditional lines. A Procure- thereof will be carried out.' A condition of effec- ment and Financial Procedures Manual is being fi- tiveness is the adoption of an acceptable Procure- nalized which will be used for the IDA Credit, but ment and Financial Management Plan. The main the Government has solicited suggestions from other assurance is tied to the process of semiannual re- TABLE 1 Category Case I Case2 Case 3 Case 4 Funds controlled by: MOE MOE MOE Donor Funds available for which components of BESIP? All All Limited One or a number small number "Pooling" of funds in common account? Yes No No No Examples of donors using each method: Dutch, Irish IDA Disbursements are made in traditional ways under BESSIP. 135 ANNEX 9: ZAMBIA EDUCATION CASE STUDY views, including approval of the Annual Work Pro- the previous year's work; the November meeting gram and Budget for the succeeding year. In one plans work for the next year, including financial pro- sense, the triggers for Phase Two are expected to be jections. The November meeting considers a draft an incentive for good performance under the first Annual Work Program and Budget for the succeed- phase. Good performance will almost automatically ing year, including an annual procurement plan for yield additional funding for the second phase. How- goods, works, and services to be financed. Based on ever, the triggers for the second phase are relatively actual experience and performance, the sector pro- imprecise, leave much to interpretation, and were gram can be revised and adapted to new circum- set at levels the Bank staff are reasonably confident stances. For example, the semiannual reviews the Government can meet so that funds can be readily monitor progress toward achievement of the targeted disbursed under the program. increase in the percentage of expenditures going to the Ministry of Education, and the maintenance of at least a 60% share for primary schools within the SWAP IMPLEMENTATION MOE budget. Implementation experience: The IDA Credit is Organization and management: Three new groups expected to be declared effective shortly. The delays were established to oversee implementation. (1) Pro- were caused because the required procurement and gram policy is guided by a Joint Steering Commit- financial procedures manual had not yet been ac- tee (JSC) chaired by the Minister of Education and cepted. The first semiannual review took place in including MOE staff, cooperating partners, and May 1999 with mixed results. Donors were disap- NGOs. All donors are eligible to attend these meet- pointed in the quality of the Government's progress ings. The JSC meets twice a year to review the work report. Considerable time was absorbed by the pro- of the previous year and plan for the following year. posal put forward by some bilateral agencies, but not The JSC is supported by a technical committee accepted by MOE, that a high-level "management chaired by the Permanent Secretary, namely, the accountant" should be appointed in the Ministry of Program Development Implementation and Moni- Education. Not much time was left for monitoring toring Committee (PIC: Four bilateral donors plus or capacity building. Ultimately, however, the do- the Bank represent all donors in the work of the PIC. nors were satisfied with the agreements reached at Day-to-day management of the program is through the review. the Management Implementation Team (MIT), in- cluding a core team of officials and component managers who are line officials. MIT is chaired by OUTCOMES SO FAR the Deputy Permanent Secretary (Technical Coop- eration). In addition, the MIT is supported by five Main achievements: sub-committees covering cross cutting issues such (1) The process of developing the SWAP has as decentralization, monitoring and evaluation, hu- forced the Ministry of Education to become man resource development and gender. more coherent and organized than it was Modus operandi: The key condition, as stated in the past. Previously, different units did above, concerns a process of twice-yearly reviews of not communicate with each other; each unit program implementation. The MOE organizes Semi- followed its own course. There was little Annual Reviews each year. (Note: In addition to the sense of working toward common objec- two Semi-Annual Reviews, there may be "special" tives. The BESSIP process significantly im- JSC meetings. For example, there has been a special proved internal communications. JSC meeting on HIV/AIDS in relation to BESSIP.) (2) Key people in Government and the donors The May meeting reviews accounts and progress on have learned a great deal about working 136 EDUCATION AND HEALTH IN SUB-SAHARAN AFRICA together toward common objectives. The to make the process truly Government- objectives of the program are much more driven. Without a minimum level of lead- widely shared as a result of the process of ership, it would be impossible to do a SIP program development. or SWAP. (3) A process has been established for dealing (2) You cannot engage in too much communi- with tangential suggestions - although it was cation with other donors. Whatever you have not applied in the case of the very late Bel- done, it is not enough. The corollary to this, gian assistance. of course, is that donor coordination takes time. It has high transaction costs and drives up the task budget. LESSONS (3) The program had high-level endorsement. The National Policy on Education had been The following lessons should be noted: reviewed and approved by Parliament. This level of approval proved helpful in ensur- (1) There must be a champion for the program ing support by other Ministries, such as the with sufficient authority and leadership on Ministry of Finance. the government side. In BESSIP the process (4) The importance of early attention to design- foundered for a while because there was no ing and installing a reporting system on key leadership. When the former Vice President variables so as to inform fully and on time became Minister of Education about 18 the semiannual reviews of progress. months ago, the leadership was established 137 ANNEX 9: ZAMBIA EDUCATION CASE STUDY TABLE 2 3249 - Zambia, Basic Ed Sec Inv Prg Project Status Report Date: 6/30/99 Region: AFR Country:; ZAMBIA Sector: EP Lending Instr: APL Prg Obj Cat: PA EA Cat: C 0PTI N tNGO? N Resettlement? N LOAN INFORMATION Agree LII ,Rev'd Cur,rency Prod Signing 4Effctive Suppl Pr] Type No. OLig Amt Amt Indicato Line Date Date ID IDA 31900 28.50 (SDR) PE 5/11/99 Total Original AmiountO(SDR): 28.50 Ttal Revised Amnount (SDR): 0.00 COFINANCING INFO TION Agency BoardAo ($M) CurrentAmount ($M) Tof ::f: X f 0 :00000:\ta ff :00 o,oo0.00 0.00 Guarantee Type: Guarantee Anount ($M): This form is part of. Initial Summary Read together with: Aide-memoire Mission End Date: lThis Form PSR Date: 5/20/99 BTO memo of: Months snce last mission: Last FormirPSR Date: )Follow-up letter of: mission planned: Total Field SUPERVISION St Total Staff Field A of EFFORT Wek $000 Week $000 6/30/99 Current FY - Planned 4.40 13.25 Current FY - Actual 7.70 25.67 0.00 0.00 Board through preceding FY 0.00 0.00 0.00 0.00 Total Actual 7.70 25.67 0.00 0.00 No. of Role or Previous UPI No. Mision Member Division Fi Days Specialization Mission 138 THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. Telephone: 202 477 1234 Facsimile: 202 477 6391 Internet: www.worldbank.org E-mail: feedback@worldbank.org Dissatisfaction with traditional projects and sector adjustment I programs led to the design of alternative and more efficient approaches to improve the impact of development assistance in the education and health sectors. These new approaches, commonly referred to as "Sector-Wide Approaches" because they cover the whole sector rather than one or more sub-sectors, are increasingly being used by the World Bank and bilateral agencies. i However, whether these new approaches will lead to the expected results will depend closely on the ability of the partners in this process to work more effectively together. In reviewing the experience to date of this approach in the World Bank's Africa Region, Education and Health in Sub-Saharan Africa: A Review of Sector-Wide Approaches provides valuable ilessons about how these new approaches can more effectively help accelerate education and health development in Africa. The i report summarizes the lessons learned and provides advice and guidance to operations staff in the Bank, partner agencies, and i governments on how to make sector-wide approaches an effective tool for provision of development assistance. 0-82 1 3-4857-4