Performance Auditing with Citizen Engagement for a Care Economy

Transcription

1 Performance Auditing with Citizen Engagement for a Care Economy Amitabh Mukhopadhyay Expert, Citizen Engagement and Performance Audit, UNDESA Cancun, Mexico, 5 th June, 2015

2 Objective To highlight the need for SAIs to focus on research-oriented performance audits on immediate matters that concern citizens rather than compliance-oriented performance audits As an example, to focus on the importance of SAIs in Mexico engaging with the demand-side concerns of citizens in the vital domain of health care

3 INTOSAI Guidelines for PAs (ISSAIs 3000 & 3100) Performance Audits to look at economy, efficiency and effectiveness can ask very different questions : Are things being done right? Are the right things being done? First type of PA combines compliance audit -- can locate the problems in implementation which is of value for public administration in the context of today If parliamentary accountability system is weak, very little is gained by compliance orientation With the second type we can add value and contribute to the public discourse in an inter-generational context of development

4 ISSAI 12 issued by INTOSAI Based on deliberations of SAIs in 2011 at UN/INTOSAI Symposium, and adoption of ISSAI 12 in 2013, INTOSAI issued the standard : The Value and Benefits of Supreme Audit Institutions making a difference to the lives of citizens This requires SAIs to DEMONSTRATE their relevance to citizens

5 Demonstrating Relevance to Citizens but HOW DO WE PROCEED? Starting point for SAIs is the Government Budget Ask the question : Is the budget merely a list of expenditures and revenues along with government borrowing? If so, what is the importance of the Finance Minister s Speech when she/he moves the motion in parliament for approval to the budget? Or the importance of other documents that accompany the Budget?

6 Government Budgets A government budget is a macroeconomic intervention in the economy which is viewed as an ever-widening circulation of goods, services, money, technologies and above all, of PUBLIC OPINION It incorporates not only fiscal policy (revenues, expenditure and borrowing) but also monetary and pricing policies revealed dramatically at times of financial crisis a relationship that constrains borrowing In the fiscal part, expenditure estimates suffer from a supply-side bias in estimating costs of activities; demand side ignored eg. quality of education, health care disregarded

7 Demand Side Concerns of Citizens in Health Care As possible subjects for performance auditing we look at : Globalisation and the Care Economy a large sample gender study on China Need for Equity and Emergency Care research and advocacy by FUNDAR, a CSO in Mexico Insurance-based approach to health for all in Mexico Seguro Popular

8 What is gender-responsive budgeting? By recognizing the CARE ECONOMY in its physical specificities and financial details, we can move towards estimates in budgets based on a better appreciation of both the underlying physical activities and financial as well as social costs involved This contributes to implementing the gender equality policy Does NOT mean a separate budget for women and applies to the revenue raising side as well as the expenditure side of budgets Involves closer scrutiny of the outcomes of budgets

9 Why SAIs should engage with GRBs GRBs are part of international commitments and part of national budgetary practices related to equity must be examined Emerging trends in performance auditing require SAIs to add value to the social discourse by bringing in an inter-generational perspective to annual budgeting Accent on citizens experience based point of view

10 Example : Health Care a global issue WHO, 2008 : Primary Health Care -- Now, More than Ever Why a renewal of primary health care (PHC), and why now, more than ever? The immediate answer is the palpable demand for it from Member States not just from health professionals, but from the political arena as well. Globalization is putting the social cohesion of many countries under stress, and health systems, as key constituents of the architecture of contemporary societies, are clearly not performing as well as they could and as they should. People are increasingly impatient with the inability of health services to deliver levels of national coverage that meet stated demands and changing needs, and with their failure to provide services in ways that correspond to their expectations.

11 China s Care Economy Sarah Cook and Xiao-Yuan Dong (2011) China's economic reforms over the past three decades have dramatically changed the mechanisms for allocating goods and labour in both market and non-market spheres. Social and economic trends that intensify the pressure on the care economy, and on women in particular in playing their dual roles as care givers and income earners in post-reform China.

12 China s Care Economy - 2 The analysis sheds light on three critical but neglected issues : How does the reform process reshape the institutional arrangements of care for children and elders? How does the changing care economy affect women's choices between paid work and unpaid care responsibilities? And what are the implications of women's work family conflicts for the well-being of women and their families? The authors call for a gendered approach to both social and labour market policies, with investments in support of social reproduction services so as to ease the pressures on women

13 The UN Working Group Proposal on Sustainable Development Goals States at point 5.4 recognize and value unpaid care and domestic work through the provision of public services, infrastructure and social protection policies, and the promotion of shared responsibility within the household and the family as nationally appropriate. Final Declaration of United Nations on Sustainable Development Goals expected in September, 2015

14 SAIs can help By undertaking performance audits of genderresponsive budgets for health care by including primary care giver at home of patients as part of the definition of health worker collecting details of the day-to-day problems faced by primary care giver in giving care and wages foregone by her/him; research methods like questionnaires/focus group discussions with households and medical staff needs involvement of CSOs Study should include Clinic Audits as developed by NHS in UK to learn how some of the problems of patients/care givers would not arise if clinic/hospital is efficient SAIs can estimate budget required to compensate care giver

15 Health Care in Mexico (2000) High levels of out-of-pocket spending exposed 50 % of Mexican households to catastrophic financial events. Since the mid-1990s, well before the implementation of the Seguro Popular, there had been a steady increase in health spending for the uninsured population; the share of total health spending for the uninsured increased from 19% in 1990 to 44% in In 2000, an estimated 3 to 4 million Mexican families incurred catastrophic or impoverishing health expenditures. The innovation behind the SP in 2013 was to create an official entitlement for the uninsured (targeting universal health coverage) as well as the increase in budget allocation.

16 Fundar, a CSO in Mexico Researchers addressed a set of poverty alleviation programs on the basis of international commitments made by Mexico Identified specific commitments made at UN Conferences at Cairo an CEDAW Identified poverty alleviation funds spent since 1998 Categorised relevant information for each poverty alleviation program Developed criteria for a gender-sensitive evaluation of the program, like Whether women s basic and immediate needs were being met or not Whether women had relevant roles as decision makers Whether there was explicit recognition of women s unpaid time and work

17 FUNDAR s advocacy work for Transparency Influencing the process for publicly reporting the federal health budget aimed at the uninsured population. The campaign played an important role in introducing seven amendments to the 2012 Federal Budget Decree that were intended to improve transparency, expenditure control, evaluation, and accountability of the SP budget. For example, before these amendments were made, the states were not required to report the total amount received from the CNPSS for the purchase of medicines. And states were not required to report the composition of total health spending, including the proportional share of out-of-pocket spending.

18 Impact of FUNDAR on funding for emergency care of pregnant women As a direct result of its gender budget analysis and lobbying efforts, FUNDAR managed to achieve a 10 - fold increase in the 2012 budgetary allocation for a national program, designed to combat maternal mortality through emergency health care provision This represented a budgetary increase in the order of US$50 million for a program that had the potential to directly benefit pregnant women, especially those from poorer, indigenous communities.

19 Should SAIs take up for PA? The budgetary increase of 2012 was not reflected in next year s budget ie. Decree of 2013, so outcome unknown The legislative changes advocated by FUNDAR and the debates in in Mexico could be revisited to comment on whether the position taken by Government in 2013 was justified

20 WHO s Global View on Financing World Health Organisation observed that : "there is growing interest in the array of domestic financing mechanisms that can be drawn upon to move towards universal coverage, including tax-based funding, social health insurance, community or micro-insurance, micro-credit and conditional cash transfers. All of these mechanisms make major demands on managerial capacity. On the other hand, where providers depend largely on outof-pocket payments for their income, there is overprovision of services for people who can afford to pay, and lack of care for those who cannot." (See WHO, 2007, Strengthening Health System to Improve Health Outcomes, Framework for Action)

21 Seguro Popular In 2003, a large majority of the Mexican Congress approved a reform to the Mexico s Ley General de Salud [General Health Law] establishing the Sistema de Protección Social en Salud [System of Social Protection in Health], which is increasing public funding to guarantee universal health-care coverage. Poor families formerly excluded from traditional social security can now enrol in the Seguro Popular [People s Insurance], a new public insurance scheme that assures legislated access to comprehensive health care.

22 Assessments Differ World Bank which supported the Social Security programme said in 2006 that it did very well. WHO Bulletin -- Harvard University and Government Medical Authorities of Mexico assessed aspects of Seguro Popular on delivery of health insurance, regular and preventive medical care, medicines, and health facilities to 50 million uninsured Mexicans -- found it did not make much difference on equity front

23 WB Report - Impact Evaluations of Seguro Popular (2006) 7.8 million -- Access to health services given for uninsured poor population excluded from social health security at an annual cost of US $ 2260 m. Impact evaluations upto 2006 demonstrated that Seguro Popular reduced health expenditures of the poor and vulnerable groups and increased their utilization of health services. Specifically, people insured by Seguro Popular had 14 percent lower out-of-pocket expenditures on drugs compared to the uninsured. Likewise, the probability of people insured by Seguro Popular to use health services when in need was 25 percent higher compared to the uninsured (Gakidou, 2006).

24 Harvard and Government Medical Departments Study 7 States, Large sample study conducted ; reported in WHO Bulletin, May 2009 Contrary to expectations and previous observational research, we found no effects on medication spending, health outcomes, or utilisation. Interpretation Programme resources reached the poor. However, the programme did not show some other eff ects, possibly due to the short duration of treatment (10 months). Although Seguro Popular seems to be successful at this early stage, further experiments and follow-up studies, with longer assessment periods, are needed to ascertain the long-term effects of the programme. Funding Mexican Ministry of Health, the National Institute of Public Health of Mexico, and Harvard University Institute for Quantitative Social Science.

25 Impact Evaluations WHO Bulletin There is a critical need for additional public funding to extend access to costly interventions for non-communicable health conditions not yet covered by the FPGC, such as cardiovascular diseases, adult cancers and the complications of diabetes. There is still a need to extend the coverage of costly interventions, which is still higher at IMSS, ISSSTE and other social security agencies.

26 WHO Bulletin (contd.) The quality of care is expected to improve further, but not unless several areas are further strengthened: the technical quality of care; drug availability, especially in hospitals; prescription patterns; care availability during evenings and weekends in outpatient clinics and emergency services; and waiting times for outpatient emergency care and elective interventions.

27 WHO Bulletin contd. Narrowing gaps in access to health services also remain a challenge, particularly in rural, dispersed and indigenous communities in Mexico s southern states. A large proportion of the resources mobilized by the Seguro Popular must be directed towards these communities to strengthen health infrastructure and the availability of human resources and basic inputs. Another challenge facing the reformed system is how to achieve an adequate balance between additional investments in health promotion and disease prevention, on the one hand, and personal curative health services on the other

28 Is Seguro Popular an answer to Out Of Pocket expenses? Have SAIs reported on economy, efficiency and effectiveness of Seguro Popular? What are their findings so far? Since Seguro Popular has been hailed as a major successful innovation to take care of a global problem of out-of-pocket expenses in Mexico, SAIs can jointly undertake nation-wide performance audit to comment on whether it is or is not

29 SAI engagement with Citizens Engagement with citizens fruitful at each stage of auditing planning, execution and reporting In research-oriented performance audits it is critical to gather information from two channels : government sources or powerful portals (media, think-tanks) from people themselves (not only media) with whom local organisations/institutions work

30 Plan of Action for SAIs on Health Care in Mexico Establish working committee with involvement of institutes of women s studies and reputed NGOs working in the provinces maybe with FUNDAR as one of the NGOs? Select one of the issues: Economy, Efficiency and Effectiveness of Seguro Popular related to OOP Expenses Estimating in the costs of care-giver and building it into Budgets -- related to SDGs Prepare an audit plan for key audit questions on the selected topic in a mode of working group meetings with NGOs Execute audits with collaboration of NGOs for gathering information from citizens and civil society -- and Report

31 Thank You!