The rhetoric of sector-wide approaches for health development

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Abstract

The past decade has witnessed an increasing concerns over the effectiveness of project-based development assistance and the promotion of sector-wide approaches (SWAps) to health as a means to increase donor collaboration, consolidate local management of resources and undertake the policy and systems reform necessary to achieve a greater impact on health issues. The concept has gained the support of both the World Bank and the World Health Organisation, as well as key bilateral donors, and dominates current initiatives in development assistance for health. This paper examines the proposal of SWAps as rhetoric, and seeks to understand how that rhetoric functions, despite the variable application of its constituent elements and the range of contexts in which it operates.

Section snippets

Rhetoric

The term rhetoric is popularly understood to be pejorative, suggesting empty verbiage or propaganda, and compared negatively with action. In this paper, however, rhetoric defines the specific form of discourse that seeks to influence social action through effective symbolic expression (Herrick, 1997, p. 6).

Rhetoric…is pragmatic; it comes into existence for the sake of something beyond itself; it functions ultimately to produce action or change in the world; it performs some task. In short,

The rhetorical context

Bitzer (1968) has pointed out that rhetorics are highly context-dependent, arising from what he terms rhetorical situations. These comprise three constituents: exigence, audience and constraints. The exigence is that “imperfection, marked by urgency” that demands change (Bitzer, 1968). For development assistance, the end of the Cold War saw changing political agendas for aid, with donors increasingly focussing on the importance of the political and social environment for the success of

Defining sector-wide approaches

SWAps are described as long term partnerships, involving government, civil society and donor agencies. Under the leadership of the national authorities, partners commit their resources to a collaborative program of work that includes the development of sectoral policies and strategies, institutional reform and capacity building. The aim of these reforms is improvement in the quality and accessibility of health serves, and consequent improvements in health. These activities are underpinned by

The rhetoric of sector-wide approaches

Aristotle defined rhetoric as the “faculty of discovering in the particular case what are the available means of persuasion” (Segal, 1993). He distinguished inartistic proofs—the known, the factual, the given—from artistic proofs—the inductive or deductive arguments that depend on the speaker for discovery or development. The art of rhetoric lay in the identification of the proofs that will support the debate, their arrangement, style and delivery. He distinguished three types of artistic proof:

Ethos

The rhetoric of SWAps is deliberately located. It acknowledges its origins within the World Bank, the most “visible” agency in development assistance both in terms of its financial resources and policy vision (Harrold & Associates, 1995; Peters & Chao, 1998; Cassels & Janovsky, 1997). The World Health Organisation has been eager to participate in the development of SWAps as part of re-establishing its policy leadership ( Cassels & Janovsky, 1998), and “like-minded” bilateral donors, including

Pathos

The same devices that establish the authority of SWAps serve to build bridges to one of the key audiences: the donor community. Both multilateral and bilateral agencies are eager to be identified as collaborators in articulating the rhetoric, as well as in the implementation of SWAps. Participation of partner governments in the shaping of the rhetoric has been more limited: to date key forums examining SWAps have had a definite focus on donors (Brown et al., 2001, Annex 1). This concentration

Logos

The recognition and anticipation of counter-argument supports the observation originally described by Protagoras that every logos has its anti-logos, or counter-argument. While these counter-arguments do not necessarily refute the arguments, and are themselves open to challenge, they need to be addressed by the rhetoric in order for it to succeed. Because the rhetorical situation arises from circumstances that demand change (exigence)—the arguments put forward find themselves “haunted” by the

Logos 1: that project aid has not been effective

Despite the global health improvements of the past 30 years, there has been broad discontent with the effectiveness of international aid expressed in analyses undertaken in the late 1980s and early 1990s (Walt et al., 1999a). While projects themselves may have been locally effective, the “unruly mélange” of uncoordinated projects has led to duplication, inconsistencies and patchy and uncontrolled development across the health system (Buse & Walt, 1997). Clift (1988) argues that it is the

Logos 2: that SWAps will ensure coordination of donor and partner resources

The lack of coordination of health projects is widely accepted as contributing to the relative ineffectiveness of project aid, but SWAps are not the first initiative to attempt to address this deficit (Clift, 1988; OECD, 1992; Cassels, 1997; Walt et al., 1999a). In their review of eight existing coordinating mechanisms, Buse and Walt (1997) note the ambiguous definition of coordination in the literature, and of the striking bias in definition towards the needs and perspectives of the donor

Logos 3: that SWAps will increase partner government ownership and control

Cassels (1997, p. 30) defines government ownership as the sine qua non of the SWAp, a view consistently reiterated by other proponents of sectoral coordination (OECD, 1992; Cassels & Janovsky, 1997). Despite the consensus on this central tenet, the massive asymmetry of power between donors and partners makes the exercise of government ownership and control exceptional (Hiscock, 1995; Buse, 1999a; Walt et al., 1999a). Given the extended process of policy development, the high visibility of SWAps

Logos 4: that SWAps will offer donors increased influence on policy, sectoral reform and evaluation

There is a tension between promising increased government control at the same time as increasing donor influence on policy and sectoral reform in SWAps. The tension arises from the need for the rhetoric to address a dual audience, extracting concessions from both sides with the promise of alternative benefits. For the changes introduced by SWAps to be sustained, local ownership is the crucial factor, but in order to secure the commitment of donors, the schedule of reform must coincide with

Logos 5: that donor support for national policies and strategies will achieve sectoral goals

The introduction of SWAps is predicated on the implicit hypothesis that assistance in creating better policy and governance in the health sector will achieve better health outcomes. This confidence is broadly supported, with Goodburn and Campbell (2001) arguing that SWAps may hold the key to reducing maternal mortality, with maternal mortality proposed as an indicator of accessible and functional health services. However, the evidence for the links between these systemic changes and health

Logos 6: that common management arrangements can be developed to negotiate priorities and strategies, monitor performance and manage finances

While the rhetoric of SWAps insists that donors use government's financial mechanisms to allocate and distribute funds, in practice, they rarely do. In terms of the practical implementation of SWAps, donors encounter their greatest difficulties in using national systems for procurement, accounting and auditing, and only a small proportion of health budgets are managed through existing SWAps (Peters & Chao, 1998; Walt et al., 1999a; Buse, 1999ab). Donor government requirements for financial and

Conclusions

It would be easy to question the viability of SWAps, given the problematic realities of implementation. For each of the key arguments that comprise the rhetoric of SWAps, critical counter-arguments are readily identified. No SWAp has managed to implement all the defining elements of the concept. Brown et al. (2001) note that “various definitions have been proposed for the broad sector approach, though the criteria defined have gone far beyond the actual achievement so far in those operations

Acknowledgements

An earlier draft of this paper was presented at the XVth International Conference on the Social Sciences & Medicine: Societies and Health in Transition in Eindhoven, October 16–20, 2000. The author would like to thank participants at that conference who offered encouragement and feedback, in particular Anthony Zwi and Enrico Pavignani. The author would also like to thank Anne Freadman, who introduced him to the concepts of rhetoric, and David Craig, who drew his attention to the work of Zizek.

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