WHY AND HOW BUDGET STRUCTURE MATTERS FOR HEALTH: FRAMING THE ISSUE

Transcription

1 WHO Symposium on Health Financing for UHC: Public Financing for UHC: Towards Implementation Montreux, 31 October-2 November 2017 WHY AND HOW BUDGET STRUCTURE MATTERS FOR HEALTH: FRAMING THE ISSUE Helene Barroy, WHO with Elina Dale & Susan Sparkes, WHO

2 BUDGET STRUCTURE = A POLICY ISSUE? Source: 2017/2018 Finance Law, Kenya Source: 2017/2018 Finance Law, Kenya. Level of resources Resource deployment Framework for accountability.

3 BUDGET STRUCTURE & APPROPRIATIONS A budget can contain multiple classifications for different purposes: o Economic classification o Functional classification o Programmatic classification From a sector policy perspective, what matters is how APPROPRIATIONS are done: o Inputs or programs? Outputs? o Or a mix? Source: 2017 Finance Law, Thailand

4 WHO PROGRAM OF WORK: HEALTH BUDGET STRUCTURE KNOWLEDGE BUILDING and dissemination: o Ongoing global review of health budget structures in LMICs COUNTRY ENGAGEMENT and policy dialogue: o Case studies on health budget structure reform: Armenia, Burkina Faso, Peru (initiated in 2017); others planned for 2018 o Country survey (30+ countries) PEER LEARNING and capacity building: o Peer-exchange seminar (Montreux, October 2017) o Training activities (e.g. Rabat, November 2017) o On-line knowledge program.

5 PRESENTATION S OUTLINE 1 Why does budget structure matter for Health Financing reform implementation? 2 Questions and findings emerging from ongoing review of health budget structures

6 BUDGET STRUCTURE & HEALTH: MATCHING MONEY WITH NEEDS? BUDGET STRUCTURE 1. Personnel 2. Services and goods 3. Transfers 4. Infrastructure? SECTOR GOALS 1. Better coverage of essential services 2. Reduction in maternal mortality 3. Improved access to HIV treatment 4. Better quality in services Source: Cashin et al: Aligning PFM and Health Financing, WHO & R4D, 2017

7 BUDGET STRUCTURE REFORM: CATALYST FOR UHC? Incentive for priority spending Legal framework for spending flexibility Enabler for strategic purchasing Booster for sector accountability

8 CONNECTING BUDGET STRUCTURE AND STRATEGIC PURCHASING REFORMS Inputs budget BUDGET STRUCTURE REFORM Program budget Setting legal framework for spending by priority programs Setting up rules for contracting services Outputs-based reporting system. Passive budget execution PURCHASING REFORM Purchasing services Using legal framework for enforcing purchasing of priority services Defining fit-for-purpose payment mechanisms Harmonized/unified reporting system.

9 BURKINA FASO: PAVING THE WAY TO STRATEGIC PURCHASING BEFORE REFORM AFTER REFORM (2017) Ministry of Health budget Personnel costs Goods and services Ministry of Health budget Public health Purchasing of health services Transfers Investments Admin & support to MoH

10 PRESENTATION S OUTLINE 1 Why does budget structure matter for Health Financing reform implementation? 2 Questions and findings emerging from ongoing review of health budget structures

11 IS HEALTH BUDGET STRUCTURE REFORM EFFECTIVE IN LMICs? Shift in all regions Input-based health budget still dominant in AFR Unfinished transition in many countries. MIXED PROG INPUTS AFR AMR EMR EUR SEAR/WPR Source: WHO, global health budget structure database n= 95 LMICs y= 2017 (or earliest available)

12 BUDGET STRUCTURE REFORM & HEALTH: COUNTRY IMPLEMENTATION CASE 1: GENERAL BUDGET BY INPUTS CASE 2: GENERAL BUDGET BY PROGRAMS HEALTH ALIGNED HEALTH MISALIGNED PILOT IN HEALTH PROGRAM LINE IN HEALTH PRESENTATIONAL INSTITUTIONALIZED

13 FROM INSTRUMENT TO INSTITUTIONALIZATION: KEY QUESTIONS Program definition What is a budgetary program in health? What type of costs to include/exclude? How to account for disease interventions? Conceptual shift in budgeting and priority setting Aligning management expenditure Appropriate financial reporting system Considering organizational implications Revising levels of controls

14 INSTITUTIONALIZING CHANGE: SHIFT IN MoH ROLE Source: Bostwana Ministry of Health o From traditional planning by inputs to multi-year prioritization by goals o Enforcing spending responsability & flexibility to funds managers o Being accountable for results o Aligning behaviors & incentives with change in expenditure management.

15 A FEW CONCLUSIONS Budget structure: important issue for health stakeholders: o Consensus on merits of budget structure reform for health o Enabler for health financing reform implementation towards UHC Transition is initiated but unfinished in health in most LMICs: o Moving from instrument to institutionalization o Need to address sector-specific operational challenges o Requires profound institutional change o Challenging reform in weak accountability systems Call for collaborative action: o Need for more joint support for stronger budgeting function in health o Critical to equip health stakeholders for sector-relevant transitions to program budgets.

16 ACKNOWLEDGMENTS WHO TEAM (HQ): Hélène Barroy, Elina Dale, Susan Sparkes SEMINAR FACILITATION TEAM: Nadège Ade (CoP/ITM), Hélène Barroy (WHO), Cheryl Cashin (R4D), Elina Dale (WHO), Grace Kabaniha (WHO AFRO), Susan Sparkes (WHO). FINANCIAL SUPPORT: DFID, GAVI, Republic of Korea

17 THANK YOU!