Integrating vertical health programmes into sector wide approaches:experiences and lessons

Abstract

The purpose of this study is to assist SDC with its decision on whether to integrate the Tanzania National TB Leprosy Programme into national delivery structures. The paper looks at experiences in three countries (Ghana, Bangladesh and Zambia), which have integrated some vertical programmes into their national systems which are also supported by a SWAp. The main finding is that integration can, and has caused problems of retaining programme performance. This can be attributed to the reorganisation of technical responsibilities, rationalisation of procurement arrangement, shortages of funding, changes in priorities and changes in government and donor relationships. At the same time however a review of other aspects of the SWAps in those countries suggests that the longer term prognosis for programme performance may be positive because there are indications of improvements in planning, financial management and accountability, greater expenditure at district level and resource allocation, swifter programme mobilisation, better linkages outside MoH and wider accountability for programme performance. In response to these findings, a number of recommendations on how to deal potential problems in Tanzania are given (section 5), and then priorities summarised (section 6). Recommendations are noted here according to when in the process they should be addressed. Issues to consider before making the decision to integrate; Reappraise the likelihood of macro-economic decline and economic shocks (e.g. natural disasters) and their possible impact on Government of Tanzania (GoT) capacity to sustain funding to any integrated programme where overall finance levels depended on GoT funds as well as donors. Also consider the possible impact of a change of government or minister, and the effect on the programme if the SWAp lost political support, Assess whether there is enough cohesion with other DPs to overcome possible future programme problems without the control offered by direct funding, Assess absorption capacity of national delivery systems to utilise available funds adequately without the impetus of a vertical programme, Assuming that the programme would then be funded through the existing district basket, assess whether SDC could maintain commitments to this pool, and how well the pool as a whole has been functioning to date in terms of timely disbursements etc. Accept a change over to integration is probably a one way event Once the decision to integrate has been made; Ensure that transition is gradual and that capacity exists before any technical and managerial responsibilities are passed on, Plan for continued capacity building after integration, including continued technical assistance, Work with MoH to consider options for retaining dedicated supervisory and technical capacity at the centre and regions after integration even if these still resemble a vertical programme approach. Pay particular attention to where supervisory and leadership responsibilities lie in the system. Ensure that there is adequate technical input to national planning processes at all levels and that the process is not overly administratively led, Ensure reporting remains robust, Ensure that during the transition phase and capacity building TB and leprosy control continue to be presented as national priorities. Also appraise national planning and budgeting mechanisms to establish how well they communicate and support national priorities, Consider earmarking pooled funding as an interim measure, Carry out a careful assessment of MoH procurement capacity in order to establish its immediate ability to procure effectively and efficiently. Anticipate having to carry out some immediate capacity building work in order to ensure that any new procurement functions operate smoothly, Try to negotiate with GoT and other DPs a procurement system which reduces transaction costs and labour intensity rather than increases them Longer term strategies to consider are; Consider helping MoH to develop specific strategies for advocacy for TB and leprosy as priority programmes with both national government (MRALG) and \nlocal government in order to try to ensure that disease control activities remain a priority, Encourage improvements in participation by local populations and better needs assessment at local level with flexibility in funding to respond to these, Carefully monitor overall expenditure of the programme in order to ensure that substitution does not take place \n

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