In Sweet Harmony? A Review of Health and Education Sectorwide Approaches (SWAps) in the South Pacific Desk Study

Transcription

1 In Sweet Harmony? A Review of Health and Education Sectorwide Approaches (SWAps) in the South Pacific Desk Study Appendix 3: Solomon Islands Health SWAp May 3, 2012 by Denise Vaillancourt Cosponsored by: Australian Agency for International Development (AusAID) New Zealand Ministry of Foreign Affairs and Trade (NZAID/MFAT) Asian Development Bank (ADB) The World Bank

2 Table of Contents Abbreviations and Acronyms Solomon Islands Health SWAp To What Extent Have the Anticipated Benefits of the Approach Been Realized to Date? To What Extent Have the National Health Objectives (NHSP , HSSP) Been Achieved? How is the Adoption and Implementation of the SWAp Affecting Program Results? 17 5 How Has the SWAp Affected the Efficacy of Each of the Donors Involved? Program Relevance, Efficacy, Efficiency, and Sustainability Preliminary Lessons and Information Gaps Annex 1. Solomon Islands Health SWAp Timeline Annex 2. Solomon Islands SWAp: Content of Various Documents Annex 3. Solomon Islands Health Goals, Objectives, Indicators Bibliography Boxes Box 1: Solomon Islands National Health Strategic Goals Box 2: Eight Priority Areas of the MHMS Corporate Plan for Box 3: Health Sector Support Program Goals and Strategic Objectives... 7 Box 4: Objectives, Components, Expected Outcomes of World Bank s HSSP TA Project... 7 Box 5: Key Indicators and Targets for the National Health Strategic Plan (NHSP) and the Health Sector Support Program (HSSP)

3 Abbreviations and Acronyms ADB ADRA AIDS ANC AusAID CBO CDP CPR DHS DOTS DP DPCG EPI EQA FBO GFATM GoSI HIS HISP HIV HMIS HSSP IDA IMCI IMR JAR JICA JPA JPR KPI LLIN M&E MDG MHMS MMR MoFT MoH MoU MTDS Asian Development Bank Adventist Development Relief Agency Acquired Immunodeficiency Syndrome Antenatal care Australian Agency for International Development Community based organization Coordinating Development Partner Contraceptive Prevalence Rate Demographic and Health Survey Direct Observation of Treatment Short Course Development partner Development Partner Coordination Group Expanded Program of Immunization External quality assurance Faith based organization The Global Fund to Fight AIDS, Tuberculosis and Malaria Government of Solomon Islands Health Information System Health Institutional Strengthening Project Human Immunodeficiency Virus Health Management and Information System Health Sector Support Program International Development Association Integrated Management of Childhood Illnesses Infant Mortality Rate Joint Annual Review Japan International Cooperation Agency Joint Partnership Arrangement Joint Partnership Report Key Performance Indicator Long lasting insecticide treated net Monitoring and Evaluation Millennium Development Goal Ministry of Health and Medical Services Maternal Mortality Rate Ministry of Finance and Treasury Ministry of Health Memorandum of Understanding Medium term Development Strategy 3

4 NCD NGO NHSP NMS NRH NZAID/MFAT PAD PIP PMIS PMTCT PS RAMSI SIG SPC STI SWAp TA TB TFR UNDP UNFPA UNICEF UNIFEM VCCT VCT WB WHO WMS YMCA Noncommunicable disease Nongovernmental Organization National Health Strategic Plan National Medical Stores National Referral Hospital New Zealand Agency for International Development/Ministry of Foreign Affairs and Trade Project Appraisal Document Program Implementation Plan Pharmaceutical Management Information System Preventing mother to child transmission Permanent Secretary Regional Assistance Mission to Solomon Islands Solomon Islands Government South Pacific Commission Sexually transmitted infection Sectorwide approach Technical Assistance Tuberculosis Total Fertility Rate United Nations Development Programme United Nations Population Fund United Nations Children's Fund United Nations Development Fund for Women (now UN Women) Voluntary confidential counseling and testing Voluntary counseling and testing World Bank World Health Organization Warehouse Management System Young Men s Christian Association 4

5 1 Solomon Islands Health SWAp 1 Evolution of the Health Sectorwide Approach 2 In 2006 the Ministry of Health and Medical Services (MHMS) issued the Solomon Islands National Health Strategic Plan (NHSP) for the period , endorsed by the Cabinet. 3 With an overall goal of improving health outcomes, the NHSP is articulated around eight strategic goals, of which six are focused on the country s key health issues, and two address, respectively, health systems constraints and community outreach (Box 1). The NHSP documents the intention of the Solomon Islands Government (SIG) to adopt a Sectorwide Approach (SWAp), whereby government and development partner (DP) funding would be increasingly coordinated and aligned around national priorities, and implementation of a national program would be under the country s leadership. The NHSP also notes that the newly elected government reconfirmed support for the SWAp in the health sector. The MHMS Corporate Plan for , which overlaps with the NHSP, specifies eight priorities supporting both SWAp (capacity building and efficiency) and health sector objectives (Box 2). Box 1: Solomon Islands National Health Strategic Goals Overarching goal: To improve the health outcomes of the people of the Solomon Islands. Strategic goals: 1. To promote a people centered approach to health; 2. To strengthen public health functions to be responsive to community health needs; 3. To reduce malaria incidence and mortality; 4. To reduce morbidity and mortality of children under five years of age due to common childhood illnesses; 5. To prevent, moderate and control noncommunicable diseases (NCDs); 6. To ensure that people s health and wellbeing will not be undermined due to the burden of HIV/AIDS and Sexually Transmitted Infections (STIs); 7. To improve reproductive health services and increase uptake of family planning methods; and 8. To strengthen health systems: 8.1 To improve management, leadership and accountability throughout MoH to achieve health outcomes; 8.2 To appropriate infrastructure reflective of identified needs and resources; 8.3 To redevelop and increase capacity and utilization of Ministry of Health (MoH) health information systems; and 8.4 To enable MoH to adopt a people centered approach to public health through organizational change. Source: Solomon Islands National Health Strategic Plan For a brief overview of health sector issues and challenges, see Chapter 1 and Annex 1 of the Main Report. 2 This synthesis is based on a timeline of key Health SWAp events, presented in Annex 1. 3 This was prepared by MHMS through a series of consultative workshops, with considerable technical assistance provided under the Australian Agency for International Development (AusAID) financed Health Institutional Strengthening Project and input from donors: AusAID, World Bank, World Health Organization, Global Fund, United Nations Children s Fund (UNICEF), Japanese International Cooperation Agency (JICA) and Republic of China. 5

6 Box 2: Eight Priority Areas of the MHMS Corporate Plan for Improvement of management and supervision of services. Improvement of access to quality care. Management and development of human resources for health care. Mortality and morbidity reduction. Source: World Health Organization (WHO), Country Health Information Profiles, Solomon Islands. Maintenance of healthy environments. Promotion of health living and lifestyles. Improvement of reproductive health and family planning. Forging of partnerships in health development. Even before the NHSP was issued, in , AusAID initiated work to develop a health sector SWAp and it subsequently sought World Bank involvement to this end. Joint (AusAID and World Bank) health missions in 2006 and 2007 explored with SIG the opportunities and risks of undertaking a health SWAp. Lessons learned from closed operations highlighted the importance of government ownership of project/program design and implementation as well as close coordination and strong working relationships among DPs and between DPs and government. In 2007 AusAID and World Bank health projects 4 came to an end and this provided an opportunity to revisit modes of assistance to the health sector. Against this backdrop, and with AusAID and World Bank assistance, MHMS undertook the preparation of a multiyear program. The Health Sector Support Program (HSSP) lays out priority themes and objectives to support focused assistance to implement the MHMS NHSP and its Corporate Plan (Box 3) over the period through a SWAp. AusAID was a very strong proponent of the adoption of a SWAp to support HSSP, as it was seeking to change dramatically its approach to aid, moving away from managing aid through large contracts and towards the delivery of aid assistance through government systems. While AusAID and the World Bank originally considered pooled support for HSSP implementation, the Bank ultimately decided to support HSSP through a technical assistance (TA) project for a number of reasons. First, the Bank was concerned about weak government leadership and capacity to establish and implement a SWAp. Underlying this concern was a change in government leadership during the SWAp preparation phase, resulting in a loss of government leadership capacity and a lack of full understanding on the part of the new leadership of the real challenges and potential benefits of a SWAp. Second, the Bank s design requirements for ensuring the fiduciary exigencies of pooled funding were acknowledged to take time to put into place, and this timeframe was incompatible with AusAID s timetable for quick(er) disbursement of health sector funding. 5 Third, there were some communication and coordination difficulties between the two agencies. Program Objectives and Design Features Objectives 4 AusAID financed Health Institutional Strengthening Project; and World Bank financed Health Sector Development Project. 5 This may have been rooted in part in broader bilateral agreements and commitments in the context of the Regional Assistance Mission to Solomon Islands (RAMSI). 6

7 The goal of MHMS s HSSP is to support the SIG in achieving improvements in priority health outcomes for the population through effective, efficient and equitable services responsive to the population s needs. Its strategic objectives are to: (i) raise service performance; (ii) improve the long term financial sustainability of public services; and (iii) improve the management of the public health system at central and provincial levels. Key interventions and outcomes envisaged under each of these strategic objectives are shown in Box 3. Box 3: Health Sector Support Program Goals and Strategic Objectives Goals To support the SIG in achieving improvements in priority health outcomes for the population through effective, efficient and equitable services responsive to the population s health needs. Objectives New standards of service performance: Support of high performing programs: antenatal care (ANC), facility based delivery, child immunization, Tuberculosis (TB); Improving performance in lagging priority services (contraceptive use, malaria control, maternal tetanus immunization, NCD services); Community empowerment to: (i) enable poorer families at high health risk to access primary services at low cost; and (ii) take control of their own health through community based activities. Foundations of long term financial sustainability of public services: Generating more revenue from tertiary services; Maintaining MHMS financing at 16 percent of total budget resources, or better; Slow migration of donor resources to capital account, leaving more of current cost financing to SIG; and Shift of allocations away from Honiara to frontline providers in the provinces. Improved management processes and accountabilities: Improving National Referral Hospital (NRH): efficiency, transparency; operational information system; human resources management; and demand management for appropriate utilization of emergency services; MHMS management of all technical assistance; Increase in pooling donors; and Improved procurement, management and distribution of pharmaceuticals. Source: Solomon Islands MHMS (2008). The World Bank financed HSSP Technical Assistance (HSSP TA) project was conceived to support the overall objectives of HSSP by providing a package of technical assistance in disciplines critical to the successful management and implementation of the HSSP under a SWAp mode. As such, it is designed around a specific development objective and key interventions that are supportive of HSSP objectives (Box 4). Box 4: Objectives, Components, Expected Outcomes of World Bank s HSSP TA Project Development Objective: To improve the institutional capacity of MHMS in the areas of public expenditure management and sector performance monitoring, critical to the overall success of the HSSP in improving health services delivery and outcomes. Components Public Expenditure Management: Technical assistance to complete the Expected Outcomes by Component Improved resource allocation and expenditure management reflecting sector priorities: 7

8 first rolling, health sector MTEF and then its annual updating, improved national MHMS and provincial health planning and budgeting systems and procedures, building on work done during preparation, so that priorities are set within a known resource envelope and linked to expected results. Sector Performance Monitoring: Technical assistance to improve the SWAp s monitoring and evaluation (M&E) framework to focus on a core set of indicators covering the key dimensions of public sector performance along key dimensions of sector performance (effectiveness, quality, efficiency, equity, sustainability) and integrating M&E into sector management. A balanced scorecard will be developed for the provinces to assess progress in meeting the strategic objectives of the NHSP. Training and Capacity Building: To strengthen the management capacity of senior managers and provincial health directors to be more effective in strategic planning and execution; it will also finance part of the MHMS strategic human resource training plan. Source: World Bank (2008b). Completion of the first rolling medium term sector expenditure program, linking resources with priorities (activities aligned with clear objectives; activities budgeted in a realistic manner; use of MTEF reflected in budget discussion and culminating in reallocation of resources to priority areas). An increase in the proportion of the health sector budget expended at the provincial level and on primary health care over baseline by 17 percent. Health facility survey completed, analyzed and used in improving sector planning and efficiencies. Increased community participation in provincial level planning. Improved sector performance monitoring system: Participatory annual joint reviews are conducted on schedule and clearly identify the main issues and formulate actionable recommendations. Comprehensive sector performance indicators and monitoring system developed. MHMS Executive making decisions based on M&E reports. Balanced scorecards for provinces and national program. Management Capacity Built: Percentage of provincial health plans implemented. Self assessment by trained provincial health directors of their management capacity three months after completion of management training. SWAp Anticipated Benefits The Solomon Islands Government is a signatory to the Paris Declaration on Aid Effectiveness, the Pacific Island Principles on Aid Effectiveness, and the 2008 Accra Agenda for Action on Aid Effectiveness. It has also articulated its definition and expectations of, and commitment to, the SWAp in various official documents, both general and health specific. 6 A review of the SWAp content of all of these documents indicates that the health sector SWAp envisaged by, and for, the Solomon Islands encompasses all dimensions of the SWAp captured in this study s conceptual framework: (i) the building blocks (or tools) for sector planning, resource allocation and coordination; (ii) the harmonization and alignment of development assistance through country led partnerships for strategic sector management (especially policy discussions, priority setting, resource allocation and regular review of sector performance) and 6 SWAp content was gleaned from a variety of official documents, notably: Solomon Islands Medium Term Development Strategy ; Solomon Islands National Health Strategic Plan ; MHMS s Health Sector Support Program PIP, Version 8, July 2007; MHMS Health Sector Support Program, Program Document, March 2008; and partnership documents, including the Subsidiary Arrangement between the Government of Australia and the SIG for the Solomon Islands HSSP ; and the Partnership Arrangement between SIG MHMS and Health Development Partners, cosigned April 18,

9 the strengthening and use of country systems and capacities for lower transaction costs; and (iii) enhanced sector stewardship culminating in the optimal use of all resources in support of national priorities, a greater focus on results and the ability to define and track accountabilities for sector performance and results. Relevant excerpts from these sources are provided in Annex 2 to document this vision. It is important to note (and will be discussed later in this chapter) that while the SWAp vision is indeed full and complete across documents (with many of the same points/dimensions articulated in more than one document) its systematic articulation across documents, in terms of objectives (or expected benefits) and (especially) indicators to monitor and measure performance, is lacking. Design In keeping with the SWAp principles, the MHMS is responsible for HSSP management and oversight, with institutional arrangements defined by the MHMS in a Program Implementation Plan (PIP). The MHMS Executive is responsible for management and oversight of the health expenditure program and service delivery. Program direction is guided through weekly Executive meetings. Strategic guidance and oversight were to be provided by bimonthly Executive special sessions, including participants from other key departments and ministries, such as Department of Finance and Treasury; Department of National Planning and Aid Coordination, and Ministry of Education, as well as donors, nongovernmental organizations (NGOs), community based organizations (CBOs) and churches involved in health sector development. 7 Responsibilities for health service programming and delivery are shared between the national and provincial levels of MHMS. Procurement of Goods, Works and Services Program activities are to be undertaken in accordance with procedures specified in the MHMS Procurement Manual, based on World Bank guidelines. 8 Although AusAID s approval of Program procurement was to be based on a mutually determined rolling procurement plan, prepared on an annual basis and shared with DPs at Joint Reviews for their review and concurrence, this is not yet happening. Quarterly monitoring updates on the implementation of the procurement plan are to be discussed during joint HSSP quarterly management meetings; and MHMS is responsible for facilitating the conduct of an annual external procurement audit by a procurement audit firm selected on a competitive basis. The procurement plan also includes the contracts to be financed under the World Bank financed HSSP TA project, with the different procurement methods or consultant selection methods, the need for prequalification, estimated costs, prior review requirements and timeframes for each contract, agreed between 7 While envisaged in the design, this has not been happening, and a revised schedule of meetings has been agreed, as noted later in this paper. 8 Procurement of civil works and goods financed through the HSSP will be on the basis of World Bank Guidelines: Procurement under IBRD Loans and Credits, dated January 1995, and revised in January and August 1996, September 1997, January 1999, January 2001, May 2004 and May Selection of consultants will be on the basis of the World Bank Guidelines: Selection and Employment of Consultants World Bank Borrowers, dated January 1997 and revised in September 1997, January 1999, May 2002, May 2004 and May

10 SIG and the Bank and specified in the plan. Procurement for TA under the HSSP TA project is carried out by government. Procurement for other TA under the HSSP, supported with AusAID pooled funding, is carried out in consultation with SIG by a contract management company hired by AusAID. The high procurement risk rating of MHMS capacity 9 culminated in an agreed action plan 10 to provide sufficient mitigation to proceed with project implementation. Financing and Financial Management AusAID pooled financing is provided through the SWAp Account (MHMS Development Partners Bank Account, replacing the Health Sector Trust Account), managed by MHMS. The Ministry of Finance and Treasury (MoFT) was to provide bank account statements for the Health SWAp Deposit Account to MHMS and AusAID on a quarterly basis (but this is not being implemented). The SWAp Account is poised, with the mutual consent of SIG and GoA, to be used as a common funding mechanism for other health sector financiers, should they emerge, via the MoFT. Annual cash flow projections are updated by the MHMS and provided to AusAID. Following their approval of cash flow projections and a formal request from the SIG, AusAID approves the provision of funds and installments. Further AusAID contributions are contingent upon the receipt of activity reports and financial reports with supporting bank reconciliations submitted by MHMS. MHMS and MoFT are responsible for Program financial management. An HSSP Financial Procedures Manual outlines procedures for the day to day management and operation of the SWAp Account. Expenditures of AusAID contributions to this account are documented in a number of ways. 11 The permanent secretaries of MHMS and MoFT and the HSSP financial management specialist were designated as the principal signatories to the account, but the latter was later dropped as a signatory as this was considered to be inappropriate. MHMS capacity is strengthened through the appointment of qualified personnel, notably: the Under Secretary for Administration and Finance; Chief Accountant; Procurement Officer; an Audit Liaison Officer (to liaise with the Auditor General s Office to provide internal audit capacity); a Financial Management Specialist; and an international accounting firm to provide support and on the job training within MHMS central office and in the provinces. MoFT/MHMS will engage the Auditor General to audit the SWAp Account annually and all published audit reports are copied to AusAID. The financial management systems to be used 9 Reasons for this rating are: (i) the lack of operational detail in the legal and regulatory framework for efficient procurement implementation; (ii) the insufficient organizational structure and capacity, and fragmented arrangement for expenditure control; (iii) the absence of procurement planning and procedural tools; (iv) a perception of widespread corruption; and (v) the limited number of local contractors, increasing the possibility of saturation, collusion, and nepotism. 10 Actions include: preparation of a procurement plan; procurement training; a procurement consultant to assist throughout implementation; a procurement manual outlining detailed guidelines for selection process, minimum qualifications, costing estimates, specification/prices; verification procedures, appropriate sanctions, monitoring expenditure claims, filing and remedies for failure to maintain records. An agreed procurement plan, procurement supervision by the Bank, and prior review thresholds also help mitigate risks. 11 Documentation includes: estimates of receipts and payments; expenditure control forms; cash books; bank reconciliation forms; quarterly activity reports; quarterly financial reports; and acquittal requests. 10

11 under the HSSP were evaluated by the World Bank for compliance with its financial management policies and procedures, and financial management risks were assessed as low. Given the low volume of transactions and the nature of procurement, disbursement methods under the HSSP TA project are limited to direct payments and reimbursement, simplifying financial management arrangements considerably. Bank financed activities are reported as part of HSSP. Annual Reviews, Monitoring and Evaluation As documented in the various partnership agreements, 12 joint governance arrangements for the periodic review of HSSP performance and for the planning and resource allocation for the following year were to be organized around two annual joint events: (i) a performance review in March to assess progress achieved in the previous year against baselines, targets and indicators specified in the MHMS HSSP document, 13 review available financial and procurement audit reports and first quarter disbursements, and inform program plans for the coming year; and (ii) a joint in depth review in September to focus on specific topics to be decided by the SIG and DPs during the March review Subsidiary Arrangement between AusAID and SIG, May 2008; Australia Solomon Islands Partnership for Development, January 2009; and Partnership Arrangement between SIG MHMS and Health Development Partners, April 2008, among others. 13 These baselines, targets and indicators were slated to be completed, possibly revised, with technical assistance envisaged under the Bank financed HSSP TA project. 14 This schedule has since been revised by the SIG jointly with the DPs in light of implementation experience to date. 11

12 2 To What Extent Have the Anticipated Benefits of the Approach Been Realized to Date? This section provides a brief tally of progress to date against anticipated capacity and efficiency benefits of the SWAp (top panel of Figure 1 1 in Main Report). Underlying factors and challenges related to the progress in realizing these benefits and their possible effect on the achievement of sector objectives are discussed and further developed later in Chapter 4. In summary, as of the midpoint of the HSSP implementation period, some of the anticipated capacity and efficiency benefits of the SWAp have been partially realized, but most of them have yet to be achieved. Only some of the envisaged tools for improved sector management and coordination have been put into place, but very recent progress indicates a potential breakthrough. The NHSP , with its eight strategic priorities, provided the overall strategic framework for the sector. The government s HSSP document (March 2008), with its five year plan horizon ( ) was not produced in a complete and final form, neglecting to include, for example, the full plans and costs of the priority programs and activities envisaged. 15 Only a partial Medium term Expenditure Framework (MTEF) was prepared in 2008 and it only covered that year. A full MTEF was pending (according to the government s 2008 HSSP document) with the specification that financing plans from MoFT and donors were needed. 16 With World Bankfinanced technical assistance and the input/support of AusAID and others, MHMS held a National Health Conference in May 2010 to discuss the draft of a new NHSP ( ). At the time of this study s data collection phase, a new MTEF was in draft and expected to be completed by the end of 2010 and fully integrated with the NHSP. MHMS also intended, with support from the HSSP TA project, to include a robust M&E framework in the final new NHSP. These were not available in time for the purposes of this study. Structures and processes for working partnerships have been established through the Joint Partnership Arrangement (JPA) between MHMS and Health DPs. Cosigned in April 2008 by the Minister of Health and four DPs, 17 this Agreement: commits to supporting the SIG in NHSP and HSSP implementation in a more coordinated fashion; acknowledges the need for predictable, timely and appropriate support to this end; expresses the intention to abide by a set of aid effectiveness principles; 18 and states the agreement to follow the governance 15 While the HSSP covered a five year horizon, and was expected to provide the costs as the basis on which to build an investment plan and serve as a building block for an MTEF, only the malaria program had a plan and costs. No other element of the HSSP document included plans or costs beyond The HSSP document acknowledges that MTEF needs to include the full term expenditure plan of HSSP for five years (investment and recurrent), as well as the resources available to finance it. Missing were: detailed plans/costs of other programs, RH, maternal tetanus, immunization catch up, NCD control, NRH/provincial hospital investments and management systems; people focus and demand side, refinement of infrastructure/equipment plan for provinces, which (according to the PAD) did not reflect the full sector envelope nor did it permit the allocation of resources or expenditures in alignment with its strategy. 17 Government of Australia, UNICEF, the World Bank, and WHO. 18 Essentially those contained in the Paris Declaration on Aid Effectiveness (2005) and the Pacific Aid Effectiveness Principles (2007). 12

13 arrangements and schedules for planning, budgeting, reporting and review of program performance. The original agreement specified two annual joint planning and review meetings in March and September. In mid 2010, SIG and DPs agreed to revise this schedule and hold three joint SWAp meetings each year, for better alignment with SIG s planning, budgeting and review cycles. These meetings were scheduled for: (i) March to review the previous year s performance and confirm the operational plan for the current year and any outstanding requirements; (ii) July to participate in a major external review and National Health Conference to inform budget planning for the following year; 19 and (iii) December following MoFT allocations to review operational plans for the following year, work plans, budget adjustments, capacity issues, and technical cooperation, among other elements. Plans for strengthening country systems and capacities for common implementation arrangements were put into place. As noted above, the SWAp builds on the planning and budgeting cycles of SIG, with capacity building aimed at strengthening these processes (through the creation and maintenance of a rolling MTEF and the strengthening of local level planning, with AusAID and World Bank assistance). The adequacy of SIG s procurement and financial management systems and capacities was assessed jointly by AusAID and the World Bank and plans for their strengthening included: guidelines, standards, the hiring of experts and technical assistance, close supervision and regular audits, with follow up. Sector performance monitoring was assessed to be in need of strengthening, with support programmed under the HSSP TA project to strengthen HSSP M&E to enable sector policy and management decisions based on evidence and to inform and facilitate the sector s review process. Some progress has been made to achieve greater harmonization and alignment of development assistance. A country led partnership involving international DPs and national actors and stakeholders has been established within which sector dialogue, strategic decision making and reviews of sector performance increasingly take place. The Solomon Islands Health SWAp timeline (Annex 1) indicates fairly regular reviews: two in 2009 and three in Other than the four DPs who signed the JPA, it is not clear to what extent these meetings invited/included civil society/ngos/fbos and other DPs who have not signed the JPA. Provincial health officers participated in these meetings, but it is not clear to what extent the SWAp has been understood and embraced by all staff and managers of provincial health offices or to what extent SWAp governance is undertaken at this level. Both AusAID, which supports the HSSP through pooled funding channeled through the SIG managed SWAp Account, and the World Bank s HSSP TA rely on country systems and capacities as the common management and implementation arrangements for planning, budgeting, procurement, financial management, and performance monitoring, with the caveat that AusAID does rely on a contract management company to undertake procurement of TA under HSSP. The World Bank HSSP TA project, as it is being implemented, both strengthens and 19 In 2011 this provided an opportunity to review the SWAp for planning beyond the HSSP. 20 First Joint Annual Review of Health (May 2009); Joint Performance Review (November 2009); Annual Joint Performance Review (April 2010); National Health Strategic Planning Workshop (May 2010); and National Health Conference and Joint Donor Performance Review (September 2010). 13

14 relies upon these systems and capacities. HSSP TA also envisages the strengthening of health information and M&E capacity to underpin the SWAp. There have, however, been no guidelines, standards, supervisions, training or technical audits of M&E systems and capacities equivalent in rigor to those put in place for procurement and financial management. The two other signatories of the JPA (UNICEF and WHO) make efforts to align their (projects based) technical and financial support around government priorities and participate in joint missions and SWAp governance meetings, but they do not rely upon country systems for procurement and financial management. This desk review has been unable to gather evidence needed to assess the extent to which the SWAp has reduced transaction costs. While the SWAp may have reduced some costs to government of previously separate interactions with DPs, it has also incurred additional transaction costs associated with the preparation and holding of joint meetings and with the reliance on country systems and capacities for SWAp management and implementation. There is no evidence to date to document the extent to which enhanced sector stewardship has been achieved. The absence of data on the efficient use of all sector resources lies in the fact that neither a baseline (a completed MTEF), nor updates (sector expenditure reviews) have been issued to date. The dialogue and program documents emphasize a commitment to results, but this has not been fully translated yet into a strong results focus. Still to be further strengthened are: SIG s capacity to align resource allocation, programming, M&E activities with the agreed expected results, grounded in a well established results chain and results framework with baselines and indicators, and simple, user friendly results reporting. Accountabilities for sector performance and delivering results have not yet been fully defined and tracked. A better articulation of roles and responsibilities within central level MHMS and between the central and provincial levels for strategic sector management and oversight and service delivery (package of services and referral system) are still needed on this front. 14

15 3 To What Extent Have the National Health Objectives (NHSP , HSSP) Been Achieved? 21 It is not possible at this juncture to assess the extent to which health sector objectives have been, or are being, achieved, especially in the context of a desk study. There are several reasons for this. First, at the writing of this report, the five year period of the NHSP ( ) had come to an end, and a new draft NHSP ( ) had been vetted with key DPs and national stakeholders; and the HSSP ( ) was past its midpoint, but there was no MTR report. To date, there has been no final evaluation of the NHSP. 22 A mid term evaluation of the HSSP was issued only in October 2011 too late to be incorporated into this study (Tyson, 2011). 23 Second, while a list of indicators was established for both NHSP and HSSP (Box 5), there is no results chain or fully developed results framework for either one. In addition, some baseline data are missing, the indicators are not fully commensurate with stated objectives and priorities within each document, 24 nor are core indicators (underpinning shared objectives) coherent across the two documents. Third, the Health Information System is in need of significant improvement (Joint Review, September 2010) and is currently unable to generate timely, key information to facilitate the strategic management and evaluation of sector performance. Fourth, this desk study does not have knowledge of, or access to, provincial level trends or evaluations of service delivery performance and outcomes. There is, apparently, good health data and trends in the country that might be more fully exploited, thanks to various surveys, analyses and the Health Management and Information System (HMIS). Nevertheless, background work supporting the preparation of the new NHSP (including the recently completed work on financing options by the World Bank) does provide some insights on health sector performance. Current services appear to be delivered very equitably, compared to similar low income countries (World Bank, 2010c). Specific achievements reported by MHMS during the September 2010 Joint Review include: relatively high levels of antenatal visits and supervised deliveries, reduced maternal mortality, and improved TB and malaria outcomes. 25 MHMS also cited challenges at the September Joint Review, especially the need to: sustain recent good levels of immunization coverage and other primary health care activities; address the challenge of growing lifestyle diseases (diabetes and cardiovascular diseases) and associated risk factors (adult obesity, smoking, betel nut chewing and related mouth cancers, and physical inactivity); and improve significantly access to safe water and sanitation services. 21 This chapter addresses the bottom panel of Figure 1 1 of the Main Report. 22 A review of past performance of the health sector was developed as part of the background preparation of the new NHSP, presented by government during the Joint Performance Review of the HSSP in September It is not available as a resource document to this desk study, but appears to be a review of trends in output and outcome indicators and not an evaluation. 23 Nevertheless, a Joint Performance Review of the HSSP did take place in Honiara in September While it provided some evidence for this study, it is important to note that it was a review of progress and not an evaluation. 24 One example of this is the absence of any behavior change indicators for prevention of NCDs. 25 Data and trends were not provided in the Joint Review. 15

16 Box 5: Key Indicators and Targets for the National Health Strategic Plan (NHSP) and the Health Sector Support Program (HSSP) NHSP ( ) Outcome Indicators HSSP Indicators Goal 1: People Centered Approach Impact Indicators and 2012 Targets MoH adopts as a core value a people focus centered on the needs and aspirations of the Infant Mortality Rate (IMR) declines from 24 in 2007 to 20 in population through a people centered approach. Maternal Mortality Rate (MMR) declines from Goal 2: Strengthen Public Health Functions (no baseline specified) in 2007 to 125 in Reduced incidence and prevalence of diseases of public health importance. Total Fertility Rate (TFR) declines from 4.6 in 2007 to 4.2 in The mental and social wellbeing aspects of health are increasingly addressed through health service Key Performance Indicators and Targets Service performance: delivery. Goal 3: Reduce Malaria Incidence and Mortality Contraceptive Prevalence Rate (CPR) increases from 25 percent to > 30 percent. Prevalence and death rates associated with malaria are reduced. Maternal tetanus (valid) increases from percent (2004 UNICEF) to > 60 percent valid. Proportion of the population in malaria risk areas using effective prevention and treatment measures. Measles immunization: from 96 percent (all) (2007 DHS) to 80 percent valid (HMIS). Reduction of infant and under five child morbidity and mortality caused by malaria. Percentage of population tested and treated for hypertension and diabetes increases Goal 4: Reduce U 5 Morbidity and Mortality (baseline and target not specified). Under five mortality rate. Malaria test confirmed (slide or other Infant mortality rate. test)/1,000 population decreases from 156 in Incidence of common childhood illnesses infants 2006 to 80/1,000. and children under five. Malaria case fatality rate declines (baseline Goal 5: Prevent, Moderate and Control NCDs and target not specified). Mortality related to NCDs reduced. TB/STIs indicator (to be determined). Incidence and prevalence of NCDs and risk factors. Financial sustainability: Goal 6: Reduce the Burden of HIV/AIDS Health sector expenditure on frontline as share Percentage (most at risk populations) who received HIV testing in the last 12 months and who know the of total health expenditure increases from 32 percent in 2005 to > 40 percent. results. SIG share of total public health recurrent HIV prevalence rate among pregnant women expenditure increases from 50 percent in 2005 Increased rate of condom use in youth, men, to > 60 percent. women. Goal 7: Improve Reproductive Health Services/Uptake of Family Planning MHMS revenues as a share of MHMS budget increases from (baseline not specified) in 2005 to > 5 percent. Maternal mortality rate reduced. Recurrent cost per hospital bed day in the NRH Proportion of births attended by skilled personnel increased. and provincial hospitals (baselines and targets not specified). Contraceptive prevalence rate increased. Management: Goal 8: Strengthen Health Systems Percentage of essential drugs list stockouts in Attitude and professional practices of health staff. health facilities that last three months: from Increased number of health infrastructure at all levels meeting minimum standards. (baseline not specified) to < 20 percent average. Increased use of evidence to support health planning and decision making. Number of provinces with two people focus programs active from 0 in 2007 to five in Health service delivery focuses on a peoplecentered approach. Note: Baselines, targets and indicators were slated to be completed, possibly revised, with TA under the Bank's HSSP TA project. These updates were not, however, available in time for inclusion in this report. 16

17 4 How is the Adoption and Implementation of the SWAp Affecting Program Results? This section explores four factors that affect the ability of SWAps to contribute to better health program outcomes (middle panel of Figure 1 1 of the Main Report): (i) the quality and relevance of the sector strategic framework; (ii) the strength of country capacity and incentives; (iii) the quality and functionality of partnerships; and (iv) the predictability, flow and use of sector resources. Quality and Relevance of the Strategic Sector Framework It is a significant, positive step that SIG has prepared a number of documents to frame and facilitate the SWAp. Nevertheless, this document review has uncovered a number of issues related to the quality and relevance of the sector strategic framework that may have undermined the efficiency and success with which MHMS has been able to carry out its work and achieve its objectives of health systems strengthening, the delivery of priority programs and services, and the achievement of health outcomes. While the HSSP is intended to be a prioritized subset of operational activities drawn from the NHSP, the relationship and distinction between these two documents is not entirely clear. This applies to the articulation of goals and objectives, the various documents that highlight (different) NHSP goals to be supported under the HSSP, and the key performance indicators. Annex 3 provides an overview of goals, objectives and indicators of the NHSP and the HSSP (as articulated in the PIP). A technical appendix documents more articulations of goals, objectives and indicators of these and other government, partnership and individual DP documents, not fully consistent across documents, which are likely to cause confusion about what the priorities are, and how they will be measured. It is not clear to what extent the NHSP and HSSP interventions are prioritized based on evidence (the highest impact interventions, based on the epidemiology and sociopolitical context). The process of its preparation (reported to be largely and rapidly prepared by consultants) raises questions about its ownership and the strength of its link to the country s needs and vision. The absence of an M&E framework, including a results chain identifying and linking inputs, outputs, processes, outcomes and impacts, for either the NHSP or the HSSP, has left the underlying program logic ill defined, providing less direction to those responsible for implementation, both at national and provincial levels. The HSSP s five year program was never fully costed, in part because a basic package of services for each program and level of service delivery/referral has not been fully defined. The original, partial draft of the MTEF was never finalized, due to the absence of full costs and to difficulties in obtaining five year horizon resource projections from SIG and DPs. It is clear, on the resource envelope side, that the MTEF would encompass all financing sources. The ownership of the MTEF, although mentioned in documents as an important SWAp building block, was not necessarily strong. The Bank was a strong advocate of a full MTEF. It does not 17

18 appear that an assessment of MHMS capacity both in terms of the numbers and skills of service delivery and other technical and managerial staff was undertaken to deliver the programs and services envisaged under the NHSP or the HSSP, leaving in question the extent to which commitments under these documents exceed the capacity to deliver them and, in the case of inadequate capacity, what measures would be taken to ensure the feasibility of plans. 26 Strength of Country Capacity and Incentives Some country capacities and systems have been strengthened to some extent under the SWAp, but there is an important unfinished agenda. The use of country systems and DPs efforts to align with country cycles for planning, budgeting, procurement, financial management and performance reviews have facilitated a learning by doing approach, reinforced by TA and training. A high turnover among senior management staff at MHMS early in the SWAp implementation phase initially set back SWAp governance, ownership, and general implementation progress, but in 2009 the new MHMS Executive s commitment and experience gave DPs reason for optimism, and the newly (2010) appointed minister was also indicating commitment and capacity to take forward the SWAp agenda and strong ownership of the new draft NHSP (Joint Mission Report, September 2010). Notwithstanding these reasons for optimism, SIG capacity to lead and manage a SWAp must not be overestimated. Two issues in particular are worth considering. First, the Solomon Islands Health SWAp does not have a SWAp Secretariat type body (as some other health SWAps in the region do), which means that there is no alleviation of the substantial incremental burden of SWAp management and implementation which falls onto the already heavy workloads of MHMS Executive. Second, while MHMS team may be well trained and highly qualified in their technical areas of expertise, their knowledge and understanding of basic SWAp concepts and principles may be incorrectly assumed. The capacity and experience of government officials to interact and negotiate effectively with DPs may not necessarily be in place, given that: (i) up until 2009 most development assistance was delivered through projects and managed outside of government through contracts; and (ii) staff turnover brought in new people who may not have been fully apprised of the SWAp approach. Implementation experience, documented through joint reviews, has pointed to a number of capacity issues that stand to undermine the full and efficient achievement of SWAp and sector goals. Planning, procurement, financial management and the coordination of joint reviews have been supported through TA, training, procedures, and guidelines. While the use of country systems may have caused delays in implementation during the initial start up of the use of these systems, they are being managed, fine tuned and strengthened as experience unfolds, albeit slowly. By contrast, sector M&E capacity has been relatively neglected. While there has been considerable investment in the generation of a substantial amount of health data (including strengthening of the health information system and the support of surveys), there has been little effort to date to assess the quality and relevance of this data or to support 26 Measures might include capacity building, and/or cutting, prioritization, phasing of activities, or a combination. 18

19 its analysis and use for learning and strategic decision making. This undermines the SWAp goals of enhanced sector stewardship and results focus. While there is record of improved staffing of key units (for example the Planning Department), SIG has raised the need for building capacity within central level MHMS, especially the financing and planning units, on the basis that the skills, capacity and number of existing staff are insufficient to take on the required work. Over and above the need for more capable staff, the government has called for a functional analysis, and a workforce/workload analysis of MHMS, whose structure has not changed since independence in This is an indication that, while assessments of financial management and procurement systems and capacities were undertaken at the outset of the SWAps to enable the use of these systems as common implementation arrangements, a more comprehensive assessment of MHMS structure, staffing, capacities and functions encompassing central level and provinces may have been in order. A number of sources highlighted the need to clarify the definition of roles and responsibilities, both managerial (between the central and provincial levels) and technical, in MHMS, including the clarification of the referral system. This would be an important tool both for reviewing and revising performance incentives. Critical tasks and functions identified in the November 2009 Joint Review report as weak or absent, and needing further attention include: (i) the development and use of a resource allocation formula; (ii) strong integration between budgeting and planning; (iii) the need for a costed minimum service delivery package; (iv) the determination by MHMS of priorities and their full reflection in planning and budgeting exercises; (v) the development of a national health workforce plan and database for human resources; (vi) completion of a staff census and a budgeted training plan; and (vii) the fuller involvement of provinces in the strategic planning process, including M&E. Quality and Functionality of the Partnership Who is in the partnership? This desk study could not find an official list of all SWAp partners, and so relied on other documentation which may not be fully accurate. The health SWAp partnership in the Solomon Islands consists of three categories of partners the public sector; national nongovernmental sector and civil society; and external (or international) partners but not everyone is equally involved. It is not clear where regional partners (South Pacific Commission SPC/Pacific Forum) fit in. In the public sector category, the MHMS is the lead coordinating partner for the health SWAp. Other government agencies that are noted in program documentation to be involved include MoFT, Ministry of Education and provincial health authorities. The November 2009 Joint Partnership Report (JPR) notes that partnerships need to be further strengthened with those already participating to some degree and with others who are not yet participating, 27 According to Joint Review reports, an MHMS staff workload assessment and analysis was emphasized by the Permanent Secretary (PS) as an early priority for the HSSP TA project in September 2008; and a functional analysis and workforce analysis was suggested again in February