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Overview of existing resource Overview of existing resource tracking efforts, tracking efforts,
methodologies and findingsmethodologies and findings
Teresa Guthrie
Centre for Economic Governance and AIDS in Africa
22
Presentation outlinePresentation outline
Why track budgets and expenditure?? Some definitions Existing efforts Findings and limitations Gaps in the information Harmonisation of approaches Conclusion
33
Govt is powerful actor in national economy so how it spends its money and how it raises money is a large determinant of health of the economy
Govt revenue and expenditure plans can potentially have powerful redistributive and developmental impact
Relative openness of budget processes and systems are key indicator or influence on degree or nature of democracy in the country
Why do government budgets matter?Why do government budgets matter?
44
Fundamental tool in implementation of public policy sets out the allocation of public resources.
More telling indicator of the priority accorded to health (or any issue) than policy or legislation
National budget is key to sustainability of any government programme
Informed budgets and funding mechanisms for health therefore enhance ability of governments to plan and implement health interventions effectively.
Why track budgets?Why track budgets?
55
Adequacy: How much is budgeted? Vs Need?
Priority: How does the budget for this purpose compare to resources spent in other areas?
Progress: Is government’s response on this issue improving?
Equity: Are resources being allocated fairly?
Using budget analysisUsing budget analysisas a resource-tracking toolas a resource-tracking tool
66
Uses of Resource TrackingUses of Resource Tracking Resource tracking identifies and measures:
All sources of funds – public, private and external Providers of services (recipients of funds, public &
private) Actual expenditure on all services Beneficiaries and outputs
Identification of what resources are available, so as to ascertain the resource gap
Mobilizing more resources to fill gaps Allocative efficiency measurement To measure trends over time – changing
priorities. Informs policy decisions
77
Uses of Resource Tracking cont.Uses of Resource Tracking cont.
Advocacy – evidence = power! Addressing equity of access to services Distinguish between Real Aid and
Phantom Aid To monitor issues of additionality of
financial and human resources To identify absorption capacity problems
and bottlenecks
88
Budget Monitoring, Expenditure Budget Monitoring, Expenditure Analysis and Resource Tracking Analysis and Resource Tracking
Assessment of Resource Need – costing analysis
Budget Allocations – indication of intended
PUBLIC expenditure
Actual Expenditure – execution of budget. Can includeall sources of funds andby all service providers
PublicPrivateDonor
Budget MonitoringProcess
Actual amountsRevenue & taxSector analysis
Expenditure
Analysis
Process/finance channels
Actual amounts
Output analysis – interim indicatorscomparing with
objectives of expenditureOutputs
EfficiencyEffectiveness
Quality
Outcome analysis – long-term indicators.Impact assessment
Life years
saved
Quality of li
fe
Reduced prevalence
rates
Causal link
Effectiveness
(CEA/CBA/CUA)
Your use of the data
will influence all
these aspects
How much was spentHow much was
allocatedHow much is needed
•Through government•Public•Foreign•Private
•In strategic programs•Targeted IEC•Condoms•PMTCT•STI treatment•VTC•ARV treatment•IO treatment•Palliative services•Social Impact Mitigation•Staff training•Research
•Through private orgs/NGOs
•At global level•At national level
•MOH•Other ministries•NGO, CSO, CBO
•At province level•Tertiary, Secondary•Primary level•NGO, CSO, CBO
•At local level
•In strategic programs•Based on need (idealistically?)•Currently covered (reality?)•Financial / Programmatic gaps
Linking Resource Need Estimates to Allocation Linking Resource Need Estimates to Allocation analysis toanalysis to Expenditure EstimatesExpenditure Estimates
1010
Existing Health & HIV/AIDS Existing Health & HIV/AIDS Resource Tracking EffortsResource Tracking Efforts
National Health Accounts (WHO NHAs) – sub-analysis on HIV/AIDS expenditure
Budget analysis studies of allocations – AIDS Budget Unit, FUNDAR, IBP, ActionAid, ELBAG, CSPR group, many civil society groups
OECD-DAC data base and NIDI Resource Flows Project for HIV/AIDS & reproductive health – donor assistance only
National AIDS Accounts (Stand alone NAAs) – only HIV/AIDS expenditure - SIDALAC
National AIDS Spending Assessments (NASAs) - only HIV/AIDS expenditure - UNAIDS
1111
1. OECD-DAC database of 1. OECD-DAC database of HIV/AIDS donor HIV/AIDS donor commitments commitments
1212
Source: OECD/UNAIDS special study: Aid Activities in Support of HIV/AIDS Control for 2000-2002.
Development aid for HIV/AIDS:Development aid for HIV/AIDS:How much is going to which How much is going to which
countries?countries?91.2
28.6
0.7
4.1
0.8
2.2
0
10
20
30
40
50
60
70
80
90
100
Nigeria
Kenya
Ugand
a
Zambia
Ethiop
ia
South
Africa
Moz
ambiq
ue
Ghana
Tanza
nia
Zimba
bwe
Tot
al m
illio
n U
SD
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Per
cap
ita
US
D
Total million USD 2000-2002
Per capita USD 2000-2002
1313
2. HIV/AIDS Budget studies2. HIV/AIDS Budget studies
1414
Civil Society groups Civil Society groups supported to supported to
undertake Health and undertake Health and HIV/AIDS Resource HIV/AIDS Resource Tracking in AfricaTracking in Africa
CEGAA works with UNAIDS, OSI and ActionAid in numerous African, East European and Asian countries.
International Budget Project supports budget advocacy throughout the world.
(Public Health as share of total expenditure)
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
2000/1 2001/2 2002/3 2003/4 2004/5 2005/6
Mozambique
South Africa
Kenya
Abuja target
Namibia – Health specific
Namibia - Total for MoHSS
Source: Guthrie & Hickey, 2004. ABU, Idasa.
Are African states meeting Are African states meeting the Abuja declaration?the Abuja declaration?
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
2000/1 2001/2 2002/3 2003/4 2004/5 2005/6
South Africa
Mozambique
Kenya
Africa ~ HIV/AIDS Africa ~ HIV/AIDS allocations as share of total allocations as share of total health expenditurehealth expenditure
Source: Guthrie & Hickey, 2004. ABU, Idasa.
1717 Source: Kioko in Guthrie & Hickey, 2004. National Aids Resource Envelope, 2003.
(2000/01-2005/06)
0
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
12,000,000
14,000,000
2000
/01
2001
/02
2002
/03
2003
/04
2004
/05
2005
/06*
Ks
hs
Other (pvt, NGOs, CBOs,FBOs)
Public Sector (government &donors)
Bilateral/Multilateral/NGOs
Total HIV/AIDS Total HIV/AIDS Expenditure in Kenya by Expenditure in Kenya by
SourceSource
1818
NB: Does not include funds from provinces' own budgets.
0
500
1,000
1,500
2,000
2,500
2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/7
R m
illio
n (n
omin
al)
Dept. of PublicService &Admin. andDept. ofScience &Tech.
SocialDevelopment:HIV/AIDSProgramme(includingcondtl grants)
Education:HIV/AIDS condtlgrant
Health:HIV/AIDS andTB Sub-programmeincludes condtlgrant
South Africa – HIV/AIDS allocations by South Africa – HIV/AIDS allocations by sectorsector
Source: Guthrie & Hickey, 2004. ABU, Idasa.
1919
Challenges/ limitations of Challenges/ limitations of the budget studiesthe budget studies
General Budget challenges: Inaccessibility and unavailability of budget
data (for budgets generally and HIV/AIDS specifically)
Previously centralised governments – access difficult & general lack of CSO participation.
Little disaggregation in budget documents. Recorded budget allocations are rarely the
actual expenditure & audited figures not easily available.
Varying budgetary and accounting systems – undermines comparability between countries.
2020
Issues specific to HIV and Aids: Lack of HIV/AIDS specific line-item in formal
budget documents. Lack of standardized classifications and
definitions. Global interest in donor allocations to HIV and
Aids (mostly not indicated on budget) Countries lack central database of donor funds. Desk review alone of formal budget documents
is insufficient to obtain adequate data – estimates of expenditure required.
Challenges cont.Challenges cont.
2121
Methodological issues: Budget allocation analysis insufficient
– need expenditure estimates, and output analysis.
Limited analysis of the services provided (nothing on target groups).
Demand not only for budget allocations, but to also identify outputs and assess the impact of expenditure.
No district level analysis – but demanded by NGOs.
Challenges cont.Challenges cont.
2222
3. NHAs NAAs NASAs3. NHAs NAAs NASAs
2323
1.1. Foreign or international or externalForeign or international or external• IFIs, bilateral, multilateral, intl corporations, intl NGOs, Rest-
of-World households
2.2. PublicPublic• Central government, sub-national government, social
security
3.3. PrivatePrivate• Households, out-of-pocket expenditure (OOPE), NGOs,
insurance
Globally, bilateral donors and multilateral agencies are the largest funding streams, although the size of these streams varies significantly by region.
NASA identifies and NASA identifies and measures funds from three measures funds from three
main financing sources:main financing sources:
2424
Flow of resources from origin Flow of resources from origin to end users: reconstruction of to end users: reconstruction of
transactionstransactions
A C
Source Provider
Functions
B
Budgetary Items Target Groups
Non Specific
2525
NASA Spending Categories/ Priorities
Proportional Spending Priorities 2005
0%
20%
40%
60%
80%
100%
Public sector Internat.Orgs
FN 8..HIV- and AIDS-Related Research
FN 7..Community Development &Enhanced Environment
FN 6..Social mitigation
FN 5..Human Resources for HIV andAIDS activities
FN 4..Prog.Devmt & HSS strengthening
FN 3..Orphans and Vulnerable Children(OVC)
FN 2..Treatment and care components Total
FN 1..Prevention Programmes
2626
NASA Treatment Components
PUBLIC Treatment Expenditure 2005
37%
16%1%
40%
6% Antiretroviral therapy.
Prophylaxis for OpportunisticInfections - mainly IPT
Treatment of OpportunisticInfections.
Hospital treatment and care.
Palliative care (incl. HBC)
2727
NASA Beneficiaries of Spending
Beneficiaries by Agent (2005)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Public sector Private sector International Orgs.
PLWHA Most at Risk Pops. Vulnerable Groups.
Accessible Pops. Gen.Pop (non-targeted) Other Pops.
2828
Private Contributions to Private Contributions to HIV/AIDS – PLWHAs carry a HIV/AIDS – PLWHAs carry a
large share large share Burkina Faso - households contribute 14% of
the total expenditure on AIDS - primarily used for traditional healers (70%) and purchasing pharmaceuticals (29%) (NAA, 2003).
Zambia – HH contributed 29% of expenditures through out-of-pocket spending. Government = 17%. Donors and cooperating partners = 46% (NHA, 2002).
Rwanda - HH contributed 16% of expenditures through out-of-pocket spending. Government = 8%. Donors and cooperating partners = 75% (NHA, 2002).
2929
2002Total HIV/AIDS expenditure = US$10.3M
Paid by Households= US$1.6M
NHA Rwanda: Households are paying a large shareof total HIV/AIDS expenditure.
Other private
1%
Public8%
Households16%Donors
75%
Source: PHRplus - NHA, 2002.
3030
NAAs ~ HIV/AIDS per capita NAAs ~ HIV/AIDS per capita expenditures LAC and selected expenditures LAC and selected African countries. PPP-USD$, African countries. PPP-USD$,
2002/3. (Pre-GF)2002/3. (Pre-GF)
0.00 2.00 4.00 6.00 8.00 10.00 12.00
BoliviaGuatemala
MéxicoChile
ParaguayEl Salvador
R DominicanaPerú
BrasilPanamá
NicaraguaCosta Rica
ArgentinaUruguay
Honduras
Q1
Q2
Q3
Q4Haiti
Burkina Faso
Ghana
KenyaRwanda
Zambia
PPP$ 7.79
PPP$ 8.12PPP$10
PPP$12
PPP$ 15
3131
NHAs – Analysis of Sources NHAs – Analysis of Sources of Expenditure on Healthof Expenditure on Health
Source: Nandakumar, A.K., Bhawalkar, et al. 2004. Synthesis of Findings from NHA Studies in Twenty-Six Countries. PHR+ Project.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ethio
pia
Kenya
Mala
wi
Moz
ambi
que
Rwanda
South
Afri
ca
Tanza
nia
Ugand
a
Zambi
a
Zimba
bwe
MENA
LAC
Per
cent
of
tota
l hea
lth
expe
ndit
ure
Donor
Private
Public
3232
Gaps in the existing Gaps in the existing informationinformation
Local government expenditure (district level) Comprehensive databases of external sources
(at international and national levels) Limited disaggregation by function (service
provided) Limited: indirect /out-patient / Home-Based
Care Limited household expenditure (different
methods) Limited disaggregation by gender and age Limited analysis of expenditure on non-health
HIV/AIDS activities Outputs and outcomes – assessment of quality of
goods and services production level, not only resource consumption level
Challenge – standardizing classifications and definitions – to ensure cross-country comparison
3333
Expanding & harmonising Expanding & harmonising approachesapproaches
Necessary for cross-country comparisons and international acceptance of findings
Therefore approaches should: Provide an inventory of ALL resources for health or
HIV/AIDS ~ public, private, international ~ (allocated budgets and actual expenditures) OR select one or more and undertake comprehensively
Standardised definitions and classifications for all the functions and categories – suggest using NHA (for health) and NASA (for HIV/AIDS) guidelines
Provide internationally comparable reports - the breakdown of tables, the content of categories and the methods of calculation must be harmonized & internally consistent
3434
Expanding & Expanding & harmonising cont.harmonising cont.
Tracking all transactions and all services provided, down to district level (where feasible).
Identification of the beneficiary groups of all services provided.
UNAIDS suggests that the methods should be compatible with the SNA /NHA / NASA systems developed over the last 30 years.
Measurement of actual outputs and outcomes, and effectiveness analysis where possible.
Broadening the network of countries and organisations involved in health and HIV/AIDS resource tracking globally.
3535
ConclusionConclusion Attention on improving economic
governance, accountability, transparency, challenging the size of the pie to health and HIV/AIDS.
Increasing efforts by governments and civil society to track the resources flowing to health and HIV/AIDS and their utilization.
Financial management and reporting systems are poor, and formal budget figures are insufficient to give the whole picture, therefore investigative research and mobilisation required!
The power is where the money is!
3636
Thank you!Thank you!
For more information contact:Teresa GuthrieCentre for Economic Governance and AIDS in Africa Email: [email protected]@yahoo.comTel: +27-82-872-4694Fax: +27-88-021-425-2852