Austerity and the “sector-wide approach” to health: The Mozambique experience James Pfeiffer, PhD, MPH a, * , Sarah Gimbel, RN, PhD, MPH b , Baltazar Chilundo, MD, PhD c , Stephen Gloyd, MD, MPH a , Rachel Chapman, PhD d , Kenneth Sherr, PhD, MPH a a Department of Global Health, University of Washington, Seattle, WA, 98195, USA b Department of Family and Child Nursing, University of Washington, Seattle, WA, 98195, USA c Department of Community Health, University of Eduardo Mondlane, Maputo, Mozambique d Department of Anthropology, University of Washington, Seattle, WA, 98195, USA article info Article history: Received 16 November 2016 Received in revised form 29 April 2017 Accepted 3 May 2017 Available online xxx Keywords: Mozambique Austerity SWAp HIV/AIDS Health system strengthening Structural adjustment abstract Fiscal austerity policies imposed by the IMF have reduced investments in social services, leaving post- independence nations like Mozambique struggling to recover from civil war and high disease burden. By 2000, a sector-wide approach (SWAp) was promoted to maximize aid effectiveness. ‘Like-minded’ bilateral donors, from Europe and Canada, promoted a unified approach to health sector support focusing on joint planning, common basket funding, and streamlined monitoring and evaluation to improve sector coordination, amplify country ownership, and build sustainable health systems. Notable donors e including US government and the Global Fund e did not participate in the SWAp, and increased vertical funding weakened the SWAp in favor of non-governmental organizations (NGOs). In spite of some success in harmonizing aid to the health sector, the SWAp experience in Mozambique demonstrates how continued austerity regimes that severely constrain public spending will continue to undermine health system strengthening in Africa, even in the midst of high levels of foreign aid with the ostensible purpose of strengthening those systems. The SWAp story provides a poignant illustration of how continued austerity will impede progress toward Sustainable Development Goal 3 (SDG 3); “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. However, the SWAp continues to offer an alternative model to health system support that can provide a foundation for resistance to renewed austerity measures. © 2017 Elsevier Ltd. All rights reserved. 1. Introduction The “sector-wide approach” to planning (or SWAp) concept emerged in health and development circles in the mid- 1990s to address growing concerns in recipient countries about uncoordi- nated foreign aid flows, NGO proliferation, and competing donor interests that were leading to fragmentation and disruptions in health sectors, especially in Africa (Sweeney and Mortimer, 2015). In most developing countries, the health sector is constituted by a “global assemblage” of health agencies, sometimes numbering in the hundreds, that include bilateral donors, UN organizations, NGOs, foundations, universities, and international financial in- stitutions headquartered in the developed world but engaged with local public national health systems in substantially different ways (Collier and Ong, 2005; Garrett, 2007; Janes and Corbett, 2009). As interest has increasingly turned to “health system strengthening” in global health practice (WHO, 2007), the question of how these assemblages impact local systems has drawn increasing scrutiny. The specific orientation of these agencies to each other and to their in-country counterparts is influenced and determined by the enduring politics and debate about how to best invest in the public sector. The extent to which these actors can coordinate their re- sources and activities with each other and their national hosts often depends on their own ideological orientation as well as the mac- roeconomic structuring of foreign aid flows into partner countries. The SWAp concept emerged out of struggles to forge common * Corresponding author. Department of Global Health, Box 357965, University of Washington, Seattle, WA, 98195, USA. E-mail addresses: jamespf@uw.edu (J. Pfeiffer), sgimbel@uw.edu (S. Gimbel), Baltazar.chilundo@gmail.com (B. Chilundo), gloyd@uw.edu (S. Gloyd), Rrc4@uw. edu (R. Chapman), ksherr@uw.edu (K. Sherr). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed http://dx.doi.org/10.1016/j.socscimed.2017.05.008 0277-9536/© 2017 Elsevier Ltd. All rights reserved. Social Science & Medicine xxx (2017) 1e9 Please cite this article in press as: Pfeiffer, J., et al., Austerity and the “sector-wide approach” to health: The Mozambique experience, Social Science & Medicine (2017), http://dx.doi.org/10.1016/j.socscimed.2017.05.008