Aid Effectiveness and Health: An Important New Report

ACTION (Advocacy to Control Tuberculosis Internationally), an international partnership of advocates fighting for resources to treat and prevent the spread of TB, released a report today (available here) evaluating the effectiveness of Sector Wide Approaches (SWAps) for health. SWAps are a funding mechanism that helps donors to pool their funding for a particular sector – in this case, healthcare – in order to pool donor funds for efficient administration and facilitate a country-led and country-owned process.

The report titled ‘Aid without Impact: How the World Bank and Development Partners Are Failing to Improve Health through SWAps,’ assesses whether efforts to strengthen health systems with SWAps have been successful in fighting TB and in delivering health outcomes. The overall conclusion is that while SWAps are an important component of the international aid architecture, changes need to be made to the way they work in order to increase their effectiveness and ensure they deliver real positive outcomes.

The report focuses initially on TB. TB continues to play a significant role in development as it disproportionately affects the poor.  Approximately 2 billion people, or one third of the world’s population, are infected with TB.  TB kills 1.8 million people every year, roughly the equivalent of 4,500 people dying every day.  Ninety-five percent of those who are infected with and die from TB live in developing countries.  Fighting TB has become all the more urgent as TB is the leading cause of death among people living with HIV.  About 80 per cent of all TB deaths among people living with HIV occur in Africa.  Furthermore, the emergence of multi- and extensively drug-resistant TB seriously threaten TB control underlining the need for a successful approach to fight the disease.

ACTION’s report notes that while the World Bank has made TB-specific investments in countries such as China and India, its strategy to address TB in Africa has been through Sector-Wide Approaches (SWAps).  The idea behind SWAps has been to pool donor finances and coordinate efforts between development agencies and governments to achieve health sector development, which is a great idea in principle as it leads to greater donor harmonisation and a more country-led and country-owned process.

However, ACTION’s report found a lack of evidence demonstrating that SWAps have worked to create positive health outcomes in sub-Saharan Africa, stating:

There is an unacceptable dearth of scientific assessment that demonstrates the impact of SWAps on health outcomes, despite the billions of dollars that have been invested in this approach since the mid-1990s.

While most people ACTION interviewed for their research identified SWAps as an essential approach to development, they admitted that “SWAps are not yet being implemented in a way that has led to improvements in health outcomes in effective, efficient, measurable, or sustainable ways.”  Additionally, the report found that SWAps have not adequately addressed or prioritised TB.

The report concludes that the World Bank and its development partners must recognise “the failure of SWAps to consistently promote better health outcomes” and should focus more on these outcomes than on process. The report recommends:

  • Regular reviews of SWAps health programmes by an independent technical team and publicising the findings.
  • Making the World Bank’s “Annual Joint Programme Reviews” that are already being done public to increase transparency and public oversight.
  • Rigorously monitoring and evaluating SWAps to establish what works and what doesn’t.

ACTION’s report coincides with International Development Secretary Andrew Mitchell’s announcement last week to create a new, independent watchdog to certify that UK taxpayers are receiving value for money.  RESULTS urges the UK and development partners to identify the release of this report as a key opportunity to improve its approach to SWAps to achieve a greater impact on health development and to focus development aid on strategies that work.

Read the full report here.


7 responses to “Aid Effectiveness and Health: An Important New Report

  1. Please note the World Bank’s Response to the June 2010 report by ACTION:

    Tuberculosis (TB) and other communicable diseases are serious health and development challenges. The World Bank, its developing country clients, and their aid partners agree that TB must be better prevented and treated in Africa.

    However, the Bank disagrees with the basic approach of “Aid without Impact”, a new report by Advocacy to Control TB Internationally (ACTION). This one-dimensional report sets out to critique sector-wide approaches (SWAps) in Africa and in particular their impact on TB. It does not consider the Bank’s work on health in Africa as a whole. Yet ACTION makes the broad claim that the Bank’s health programs fail to improve health outcomes. This claim is based on weak methodology and a linear look at a complex picture involving many actors and multiple health sector reforms being implemented in parallel.

    The Bank is focused on achieving tangible results. It is committed to carefully monitor results on the ground and is widely acknowledged as a leading institution in the area of monitoring and evaluation. For example, the Bank has carried out hundreds of randomized trials of development innovations and invests heavily in building national capacity to measure socioeconomic progress.

    A number of different partners are involved in SWAps in Africa. Notably, the World Bank provides a relatively small share of the financing—usually less than 20 percent—with many other donors contributing. For example, in the large Tanzania SWAp, the government is by far the largest financier. Of the numerous donors’ contribution to this SWAp, the World Bank only accounts for about 15 percent. Partners currently contributing to the pooled funds include Canada, Denmark, Germany (GTZ and KfW), Ireland, Netherlands, Norway, Switzerland, UNFPA, UNICEF and the WB. Other major donors outside the pool include DfID, USAID and the Global Fund.

    The majority of World Bank health operations in Africa do not involve SWAps. The Bank has 50 ongoing health operations in Africa, including projects covering health systems, communicable disease control, and nutrition. Of these, less than 10 percent support SWAps. It is therefore unclear why the report, which is largely about SWAps, headlines the World Bank. While the report surfaces a number of useful observations, many of which have already been expressed by the Bank’s Independent Evaluation Group, it is incorrect in attributing most SWAp weaknesses to the Bank.

    The Paris declaration principles behind SWAps (and other similar approaches) are fundamentally sound—country ownership, a single strategic framework including for monitoring and evaluation, coordination, and lower transaction costs for governments. In practice, more attention is required to results, and on this point the Bank is in agreement with the ACTION report.

    That is why the World Bank has stepped up support for results-based approaches and is increasingly rolling out rigorous impact evaluations to understand what works and what does not. The Bank emphasizes Results-Based Financing (RBF)—a primary component in, for example, a recent health system performance project in Benin. The Bank is working with 24 governments in Africa on RBF, including 10 countries in which the Bank is currently providing financing. RBF efforts are much more common than SWAps in the Bank’s portfolio and many include indicators related to TB.

    With regard to TB, the Bank is particularly concerned with the rise of multi-drug resistant strains which can spread easily within and across countries, and with the poor diagnostic capacity seen in vulnerable regions. A key project launched recently is the US$63.66 million East Africa Public Health Laboratory Networking Project across Kenya, Tanzania, Rwanda and Uganda—where TB-HIV co-infections are highly prevalent. This is an innovative, next-generation effort to speed up the accurate diagnosis and hence rapid treatment of key communicable diseases, including TB, among vulnerable populations living in cross-border areas. The project seeks to forestall potential epidemics that could occur with the thinning of economic borders in the region and greater labor mobility going forward. It serves not just TB patients, but all patients, and draws on expertise from other leading health agencies.

    (You can read more about this project at : )

    Finally, it is noteworthy that in 2007, after extensive consultations with WHO, the UN health agencies, country clients, and various foundations, the Bank was asked—based on its comparative advantage—to help countries strengthen their overall health systems to achieve better health for mothers, children, families, and communities. Fewer TB infections is one of these many health outcomes that is a high priority for the Bank and its clients. The Global Fund to Fight AIDS, TB, and Malaria; the WHO; the Stop TB partnership; and the TB Drugs Facility are at the forefront of this fight, while the Bank works with countries to build stronger underlying health systems that will help governments and disease-specific agencies to deliver more sustainable results over the long term.

  2. Abdul Musa

    Mr Hey, have your expensive programmes been proven to significantly advance the control of tuberculosis in Africa? Or is it that you simply do not know? That seems to be what the report is questioning from what I have been reading.

  3. Dear Mr. Musa,

    Phil Hay is traveling today and without access to a computer. He will respond to you as soon as he can post a comment.

    Just so we understand your question clearly in the meanwhile, are you asking about what the SWAp in a given country has achieved on TB? SWAps have multiple development partners including governments; the Bank is one among many partners.


  4. Vivek Dharmaraj


    I have to say your response relies heavily on your statement that the WB is “widely acknowledged as a leading institution in the area of monitoring and evaluation”. However, both the 1999 and current reports by the IEG have said that M&E was very weak in the projects that the bank supported. The 1999 ARDE says that “…development activities must be guided and judged by results” but the last report says “some aspects of monitoring have improved but overall it remains weak, and evaluation is almost nonexistent.”

    The advances and steps made in various sectors, (especially TB) must be attributed more to organizations like the Global Fund, multilateral and bi-lateral agencies than to SWAps. Global collaboration and sharing of models, expertise and learning brought about through innovative processes encouraged by GFATM have contributed to great gains.

    It would be useful to take a look at SWAps and finding ways to improve their effectiveness. However, change will only come if you accept there are things that need changing

  5. Dear Vivek, thanks for your thoughtful comments. M+E is essential to achieving the better health and development outomes that are central to the MDGs and this process should be continuous thought out the life tiem fo the operation. We’d all agree on this.

    But what surprises me are comments that suggest that the authors of the Action report should be regarded as the ultimate experts in SWAps and their impact on Tb. Where are the government and country voices in these superficial reviews of SWAps ? Where’s the acknowledgement of country ownership ? Or is this a case of paternalism on the part of RESULTS and Action ? I see lots of interviews with experts at the global level but almost nothing from government ministers and country experts whose overall health plans are financed by SWAp donor financing. In the case of the Tanzania health SWAp, the government is the major financier.
    One other thing is that since 2007, the Bank, at the request of developing country governments and the UN health agencies and other key partners, has been committed to helping low-income countries strengthen their underlying national health systems. This means being able to provide prevention, care, and treatment services for people regardless of what illness or disease may be making them unwell. A very Bank recent example of how a stronger health system can work across all diseases is the 63 million dollar East Africa Public Health Laboratory Networking Project which will speed up testing for and treatment of many communicable diseases, including Tb and multi-drug resistant Tb strains, in Kenya, Tanzania, Rwanda, and Uganda.
    Lastly, the Bank is currently involved in 50 health operations in Africa to improve health, nutrition, and population outcomes. Of these less than 10 percent of these support SWAps. For RESULTS and ACTION to then say that SWAps are the Bank’s preferred approach to working in health would appear to be erroneous. Furthermore, why is the Bank being singled out for critical attention al critical treatment when many partners contribute to the overall implementation of SWAps. Consider in the case of the Tanzanian SWAp, partners currently contributing to the pooled funds are Canada, Denmark, Germany (GTZ and KfW), Ireland, Netherlands, Norway, Switzerland, UNFPA, UNICEF and WB. Other major donors outside the pool include DfID, USAID and Global Fund.

    Let’s have substantive discussions without the megaphone point-scoring which RESULTS and ACTION appear to be engaged in without balancing their advocacy efforts with African government perspectives.

  6. The ACTION team have just posted a reply to the points raised in the World Bank’s response that Phil shared above, welcoming the chance to dialogue openly about the findings with the World Bank. It is comprehensive and can be read at:

    Some passages taken from the rebuttal are:

    Aid Without Impact focuses on low-income countries in Africa. Nowhere do we issue findings about the Bank’s overall health portfolio. The main point of Aid Without Impact is to highlight the need for the World Bank and others who support SWAPs to pay more attention to alleviating as rapidly as possible, in cost-effective ways, the highest burdens of disease, especially of the poor.

    The World Bank’s response to Aid Without Impact claims that the institution “is committed to carefully monitor results on the ground and is widely acknowledged as a leading institution in the area of monitoring and evaluation.” Indeed, we commend the Bank for its pioneering work on Results Based Financing (RBF). We also commend IEG for the first comprehensive review of SWAps and its excellent review of the Bank’s Health, Nutrition and Population (HNP) efforts over a decade. Like others, we also greatly appreciate the seminal work done by teams like those of David Peters and David Gwatkin on the measurement of the impact of projects on the poor.

    Monitoring and evaluation (M&E) is necessary to gauge how well projects are delivering results as intended and how effectively and efficiently they apply resources. However, contrary to the Bank’s claim, the Bank’s own evaluators have found the Bank to be widely neglecting M&E in its health efforts.

    Aid Without Impact acknowledges, along with the Bank, that SWAps involve multiple donors and support efforts to address myriad challenges facing weak health systems. The report’s recommendations are indeed directed at the World Bank and other donor agencies-all of which must do better to ensure that SWAps deliver better outcomes for the poor.

    We agree with the Bank’s assertion that the principles behind SWAps are sound. As we write in the report, “The validity, in principle, of SWAps is not in question.” Rather, we assessed the extent to which SWAps have been shown to lead to improvements in health outcomes as envisioned when the approach was conceived and eventually widely implemented. We found that in Africa they have not delivered as promised, and we therefore offered recommendations for improving their implementation. Our recommendations are quite consistent with those offered by IEG.


    We highly recommend that you read the full rebuttal here:

  7. Pingback: RESULTS responds to the government’s Comprehensive Spending Review | RESULTS UK – The Power to End Poverty

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