Ministry of Health / Ministry of Finance Toolkit December 11, 2014 Montreux, Switzerland Abt Associates Inc. In collaboration with: Broad Branch Associates Development Alternatives Inc. (DAI) Futures Institute Johns Hopkins Bloomberg School of Public Health (JHSPH) Results for Development Institute (R4D) RTI International Training Resources Group, Inc. (TRG)
Y1 CB Activity 6: Toolkit for MOH to work more effectively with MOF What is the problem? MOH and MOF lack common language, systems, priorities, and incentives Few opportunities exist for dialogue on priorities and funding MOH compete with other sectors for limited resources MOH needs to be prepared to answer questions such as: Did you spend all the resources allocated to health? How did you spend those resources? What results did you generate? How can resources be spent more efficiently?
HFG s Contribution Five tools focused on improving MOH ability to demonstrate performance, accountability, efficiency and responsiveness. Guided Self-Assessment of Public Financial Management Performance Self-Assessment of Internal Control Developing Key Performance Indicators for Health Collecting Data for Efficiency Conducing Health Sector Performance Audits (2015)
What s in a HFG Tool? Tools targeted at MOH officials directly involved in functions associated with MOF collaboration. Description of problem, issue Step-by-Step process Templates and tables Country example
Tool 1: Guided Self Assessment of Public Financial Management Performance Adapting the Public Expenditure and Financial Accountability (PEFA) review for the health sector Focus on 12 (of 31) indicators most relevant to health Providing MOH officials a macro level view on PFM to: Develop PFM roadmap Respond to MOF request for fiduciary assessment Provide policy makers with risk assessment Inform MOH internal review cycle
HFG Tool Indicators 1. Expenditure against original budgets 2. Monitoring expenditure arrears 3. Public access to fiscal information 4. Medium term planning, budgeting and spending 5. Cash flow predictability 6. Payroll controls 7. Transparent procurement system 8. Formal internal control 9. Internal audit effectiveness and accountability 10. Strength of accounting system 11. Data generated by accounting system 12. Use of donor financial information for budgeting and reporting
Self-Assessment of Public Financial Management Performance Indicator 3: Public Access to Key Fiscal Information Score A B C D Minimum Requirements MOH makes available 5-6 of the 6 listed types of information MOH makes available 3-4 of the 6 listed types of information MOH makes available 1-2 of the 6 listed types of information MOH makes available 0 of the 6 listed types of information
Tool 2: Internal Control Self Assessment What is Internal Control? In pursuit of an entity s mission, the following general objectives are being achieved Executing orderly, ethical, economical, efficient and effective operations; Fulfilling accountability obligations; Complying with applicable laws and regulations; and Safeguarding resources against loss, misuse and damage
The Self-Assessment Process Conducted every six months Estimated 3 to 4 week duration; teams of 2 to 6 people Sampling of facilities based on rural/urban, geography, and size. Report highlights areas of strength and weakness in five areas: Control Environment Risk Assessment Control Activities Information and Communication Monitoring
Indicators of Internal Control General Assessment Inadequate (-1) Rating Needs Improvement (0) Adequate (+1) There is a "Code of Ethics The organizational structure is supportive of a control environment.
Tool 3: Key Performance Indicators Global shift from input-based budgeting to program and performancebased budgeting, resulting from: Increasing citizen demands for government accountability and results Increasing legislative scrutiny of government operations Tighter budgets and the need to economize and justify spending What are KPIs? Measures used to define success and track progress in meeting strategic or long-term goals. Used to: Establish baselines; Set performance standards; Measure and report improvements over time; Compare performance across geographic locations; Benchmark performance against regional and international peers; Allow stakeholders to independently judge health sector performance.
Linking KPIs to Strategy Using a Logic Model to Sharpen Focus on Strategic Plan Goals Problem or Need Policy Goal People mostly visit health centers when they experience illness or injury, not as part of routine or preventive health maintenance, driving up healthcare costs and the incidence of preventable medical conditions. Create incentives for proactive health maintenance (e.g., reduced-fee or free preventive visits), and/or disincentives for unhealthy habits (e.g., sin taxes on the consumption of specific items, such as tobacco or alcohol). To reduce morbidity and its costs to society through enhanced incentives to practice healthy lifestyles.
and from Strategy to Programs Figure 2. Logic Model for Program Planning Inputs Activities Outputs Outcomes doctors, medicines, clinics routine exams, screening, vaccination, health education reduced emergency visits, hospital admissions, etc. reduced morbidity/ reduced healthcare costs
Challenges with using KPIs Making KPIs SMART Specific, Measurable, Achievable, Relevant, Time-bound Linking country strategies to programs, and programs to budgets Generally part of a whole of government initiative to move towards performance budgeting Requires a change in organizational structure and incentives Takes time to implement
Tool 4: Data for Efficiency Issue: Expanding fiscal space for health can also come from efficiency gains. How can MOHs properly assess internal efficiency across their operations (i.e. deployment of health personnel; utilization of medical products and technologies; and use of health facilities and care)? Objective: Tool helps to understand and assess efficiency in the use of resource inputs, illuminating pain points allowing MOHs upper management to: Assess management performance Strengthen budget preparation and justification in the annual budget preparation process Assist in health planning and policy understanding where to focus efforts to improve health services.
Defining Efficiency in Health Care Definition Productive Efficiency Outputs cannot be produced with less of some input Technical Efficiency Outputs cannot be produced at lower cost Allocative Efficiency No person can be made better off without making someone else worse off Opportunity Reduce waste Save money Maximize social value Sample Inefficiencies 1. Excessively low bed-occupancy rate 2. Expired drugs and IV fluids 1. Unnecessary use of antibiotics 2. Inadequate lengths of stay 1. Bednets versus polio vaccines 2. Wrong scale and scope in hospitals
Efficiency in Health Care: Sample Indicators Staff Utilization Health Technologies/ Health Facilities pharmaceuticals Density of physicians/nurses Percent use of generic drugs Ratio of Administrative Cost to Total Cost Patient loads and time spent Minimization of waste in Service Wait Times with patients medicines (% destroyed) Ratio of wages outlays to G&S spending Lab turnaround time Average Length of Stay (ALOS) Health workers attendance rate Usage levels of high-value equipment Bed Occupancy Rate (BOR)
Data Collection, Reporting and Use Data might or might not already be available If not, plan surveys across geographic areas and health facilities (primary, secondary tertiary). Prepare on a yearly basis Used for internal purposes, but also..as input for budget justifications to the MOF, including: Successes in health resource use (productivity and utilization rates) Issues, findings and recommendations MOH efforts/initiatives for attacking issues
Tool 5: Performance Audit for Health (2015) Why performance audit? Who is the primary audience for this tool? What expertise is required to conduct a performance audit (and to use this tool)? What are the key steps in conducting a Performance Audit? Planning setting objectives; audit questions; indicators of performance; sources of evidence etc. Field work Reporting Follow up
Thank you https://www.hfgproject.org/ Abt Associates Inc. In collaboration with: Broad Branch Associates Development Alternatives Inc. (DAI) Futures Institute Johns Hopkins Bloomberg School of Public Health (JHSPH) Results for Development Institute (R4D) RTI International Training Resources Group, Inc. (TRG)