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Resource Tracking for Financial Accountability. Nirmala Ravishankar Washington, DC January 25, 2010. Outline. Brief Introduction to National Health Accounts NHA as one of many Resource Tracking Tools Harmonizing Resource Tracking Tools to Improve Planning and Financial Accountability

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Resource tracking for financial accountability l.jpg

Resource Tracking for Financial Accountability

Nirmala Ravishankar

Washington, DC

January 25, 2010


Outline l.jpg
Outline

  • Brief Introduction to National Health Accounts

  • NHA as one of many Resource Tracking Tools

  • Harmonizing Resource Tracking Tools to Improve Planning and Financial Accountability

  • Ongoing Harmonization Efforts in Rwanda



National health accounts nha l.jpg
National Health Accounts (NHA)

Method for measuring total expenditure on health in a country including public, private, and donor contributions

Builds on OECD’s system of health accounts

Internationally accepted and tested (100+ countries)

Application to priority areas has led to development of NHA subaccounts

HIV/AIDS subaccounts

RH subaccount

Malaria subaccount

CH subaccount


Nha tracks both the amount and flow of funds through the health system l.jpg
NHA tracks both the AMOUNT and FLOW of funds through the health system

MANAGERS of funds: Have power and control over how funds are used i.e., programmatic responsibilities: e.g. MOH, insurance companies

Financing Source

$

Financing Agent

End USERS of health funds: Entities that provide/ deliver health service . e.g., hospitals, clinics, health stations, pharmacies

Originators of health funds: e.g., MOF, households, donors

Actual USE of funds: Service and/or product delivered. e.g. preventive programs, curative care, admin

Health Provider

$

Function

$

$



To do that it uses a variety of sources l.jpg
To do that, it uses a variety of sources health system

  • Executed budget of the government

  • Institutional surveys

    • Donors and UN agencies

    • NGOs and other implementing partners

    • Employers

    • Insurance providers

  • Household survey of health expenditure

  • Secondary data sources

    • HMIS

    • Facility data on utilization

    • Others



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International assistance accounts for biggest share of health resources in Rwanda

53%

1%

28%

42%

50%

33%

25%

52%

42%

19%

40%

30%

32%

25%

10%

18%


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NGOs and international agencies emerge as biggest managers of health spending in Zambia

Total: $133,918,260

Total: $164,810,839


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Reflecting on NHA in Africa: The need for institutionalization

But NHA estimations continue to be costly,

time-consuming, and require considerable external technical assistance.

At least 25 countries are completing or have done an NHA.

Some – like Rwanda – have done multiple rounds.

Egypt

Mali

Niger

Burkina Faso

Nigeria

Ethiopia

Liberia

Uganda

DRC

Cote d’Ivoire

Kenya

Ghana

Rwanda

Togo

Tanzania

Benin

Malawi

Zambia

Mozambique

Zimbabwe

Mauritius

Namibia

Use of NHA needs to be enhanced.

Madagascar

Botswana

South Africa



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Demand for harmonized resource tracking institutionalization

Harmonized resources tracking is a key part of the institutionalization agenda.



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What is resource tracking for health?* institutionalization

  • Health resource tracking tools measure and analyze the flow of financial resources for improving health

  • They track how much is flowing, from whom, through whom, to whom, and for what purpose

*Sources: Powell-Jackson & Mills, A Review of Health Resource Tracking (2007); Berman, National health accounts in developing countries (1997), Schieber and Poullier, International health care spending (1986); Levine and Blumer, Gaps and Links: What do we know about resource flows in global health (2004); Ravishankar et al., Financing Global Health (2009).


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Two levels of resource tracking institutionalization

  • International development assistance for health

  • Resources for the health sector within a country


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International resource tracking tools institutionalization

  • Track international resources for improving health in developing countries

  • Typically focus on commitments, disbursements, and in-kind services (medical commodities, TA)

  • Examples:

    • OECD-DAC’s databases

    • IHME’s development assistance for health database

    • PLAID database


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National resource tracking tools institutionalization

Some are focused on the health sector while others are not

  • Track the flow of funds within a single country

  • Many RT tools at the country-level have been standardized internationally

    • National Health Accounts (NHA)

    • NHA subaccounts (HIV/AIDS, RH,etc.)

    • National Aids Spending Accounts (NASA)

    • Development Assistance Database (DAD)

    • Public Expenditure Tracking Surveys (PETS)

  • Countries have developed additional tools reflecting their needs

    • E.g., Joint Annual Work Plan (Rwanda)

Some are disease-specific

Some assess past expenditures while others focus on budgets


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Distinguishing between different kinds of institutionalization“tools” in use in developing countries

Multi-Sector Assessment

e.g., PER

Multi-Sector Planning

e.g., MTEF

Health Sector Planning

e.g., Health sector plans,

national AIDS strategies

Health Sector Assessment

e.g., Health PER

Costing

e.g., MBB,

HIV/AIDS costing tools

Resource Tracking

e.g., NHA, NASA,

PETS, DAD


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Purpose of resource tracking institutionalization

To generate evidence that can:

  • Enhance coordination among donors at the international level

  • Feed into the planning cycle and improve resource allocation at the national level

  • Be used to mobilize more resources for neglected areas and the health sector as a whole, both internationally and nationally

  • Be combined with measures of health system output and outcomes to assess the performance of health systems

  • Improve financial accountability by tracking flow of resources from financial source to the service it was used to deliver


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Harmonizing Resource Tracking Tools to Improve Policy Planning and Financial Accountability


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What does harmonization of resource tracking mean? (1) Planning and Financial Accountability

Rationalizing data collection systems so as to reduce the burden of data reporting and increase efficiency

  • NHA HIV/AIDS subaccount and NASA have considerable overlap. Combining data collection efforts reduces burden of reporting and saves both time and money (Rwanda, Namibia, Ethiopia, DRC)

  • Including health expenditure questions in ongoing household surveys like the DHS, MICS, PLWHA surveys, etc. saves need for stand-alone surveys (Rwanda, Namibia, DRC)

  • Tracking facility-level expenditures as part of a country’s district-level HIS can generate much-needed information cheaply and on a routine basis (Rwanda, Liberia)


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What does harmonization of resource tracking mean? (2) Planning and Financial Accountability

Greater coordination between donors and government agencies

  • Donors work with different government agencies in the same country. They each have different timelines and deadlines, which need to be synchronized (Rwanda)

  • To be relevant, RT information needs to be produced at the right time in the Government’s planning cycle (Kenya and Rwanda)


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What does harmonization of resource tracking mean? (3) Planning and Financial Accountability

Build linkages between RT systems to increase financial accountability

  • OECD-DAC tracks commitments and disbursements to the implementing partner in a country. NHA and PETS track what happens to the money once it enters the country and how it is spent. Combining these two will lead to complete financial accountability.

  • In Rwanda, JAWP tracks planned expenditures while NHA tracks actual expenditures. Ideally, you would like to be able to compare planned with actual expenditures by different actors.


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Rwanda Planning and Financial Accountability’s Resource Tracking Harmonization Initiative


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Rwanda is a pioneer in the resource tracking realm Planning and Financial Accountability

  • Rwanda has implemented multiple rounds of internationally recognized resource tracking and resource allocation analysis tools including

    • National Health Account (NHA) and subaccounts for HIV/AIDS, malaria and RH

    • National AIDS Spending Assessment (NASA)

    • Development Assistance Database (DAD)

  • It has developed resource tracking systems of its own to suit the purposes of GoR and its development partners

    • Joint Annual Work Plan (JAWP)


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Despite these achievements, significant challenges persist Planning and Financial Accountability

  • While each of the activities serves a valuable function in its own right, they collectively place a heavy burden on all stakeholders

  • Harmonization of different resource tracking activities is needed to:

    • Reduce the burden of data reporting

    • Build analytical linkages between the different resource tracking exercises

  • Domestic capacity for undertaking resource tracking is low


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Ongoing harmonization efforts in Rwanda Planning and Financial Accountability

  • Undertake a systematic review of all RT activities in the health sector

  • Design and implement a harmonization strategy over the next six months to create ONE resource tracking system which

    • Rationalizes institutional data collection

    • Synchronizes RT with the government’s planning cycle

  • Implement harmonized resource tracking with Rwanda School of Public Health, specifically:

    • Train them to undertake RT exercises upon request from MOH

    • Develop RT curriculum as part of regular curriculum which they can use to train others

  • Include household expenditures questions in the upcoming DHS


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Harmonizing data collection platforms: Reviewing inputs Planning and Financial Accountability

We need the Ministry’s detailed planned and executed budgets.

  • NHA Inputs

    • MOH executed budget

    • Donor and NGO surveys

    • Employer survey

    • Insurance survey

    • Household expenditure survey

  • NASA Inputs

    • MOH executed budget

    • Donor and NGO surveys

    • Provider survey

  • JAWP Inputs

    • Donor and NGO surveys

    • MOH planned budget

If we don’t coordinate data collection, we will be approaching partners 3 times!


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Harmonizing timing of data collection: Pending questions Planning and Financial Accountability

When is MOH’s budget for upcoming FY finalized ?

July 2009

Government of Rwanda

June 2010

When is MOH’s executed budget for past FY finalized?

Is it correct to assume that on-budget support will follow same planning and execution cycle?

When can implementing partners report their planned expenditures for the next FY?

Oct 2009

Sept 2010

USG and all its implementing partners

When can implementing partners report expenditures for past GoR FY?


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Conclusion Planning and Financial Accountability

  • NHA has made great strides in Africa and around the world

  • The larger NHA stakeholder community is rightly focused now on NHA institutionalization

  • Harmonizing NHA with other resource tracking activities and the planning cycle of developing countries is a key part of the harmonization agenda

  • It will serve the dual purpose of:

    • Making NHA production more efficient and reduce burden of data collection

    • Generate greater demand for and policy use of NHA data


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Further Readings Planning and Financial Accountability

Using NHA data for policy use and policy reform

  • NHA accelerates pro-poor reforms in the health sector in Kenya http://healthsystems2020.org/content/impact/detail/2290/

  • From Emergency Relief to Sustained Response: Examining the Role of the Private Sector in Financing HIV/AIDS Services

    http://www.psp-one.com/files/5355_file_From_Emergency_Relief_Final_Report.pdf

    On harmonization of resource tracking tools:

  • Linking NASA and NHA: Concepts and Mechanicshttp://healthsystems2020.org/content/resource/detail/2321/

  • National Health Accounts and Public Expenditure Reviews: Redundant or Complementary Tools?http://healthsystems2020.org/content/resource/detail/2240/


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Thank you Planning and Financial Accountability

Reports related to this presentation

available at www.healthsystems2020.org


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