Pets Study-pwc 1999

8/14/2019 Pets Study-pwc 1999

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PUBLIC EXPENDITURE TRACKING STUDY

REPORT FROM PRICE WATERHOUSE COOPERS


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q~..~L.""'~'~rt .f' uDL1L .t.AYi~j)l fURE REVIEW:HEALTH AND EDUCATION FINANCIAL

TRACKING STUDYCONTRACT REFERENCE TAN I06/4

VOLUME I - DRAFT FINAL REPORT: SUMMARY OFOBSERVATIONS, CONCLUSIONS AND RECOMMENDATIONS:YIARCH 1999


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, ~~ -!~. . .! . '; ... " .:' rY"PENDITURE REVIEW: HEALTH AND EDUCATION

" --". -~.LA L TRACK ING STUDY - CONTRACT REFER ENCE TAN 106/4VOLUME 1- DRAFT FINAL REPORT - SUMMARY OF OBSERV ATIO N~CONCLUSIONS AND RECOMMENDA T IO~S - MARCH 1999I Introduction 3 ~:II R esources disbursed trom central governm ent and donors to district c ouncils 9 ,::III Sources and management of resources at d istrict councils .18 -IV Sources and m anagement of resources at primary schools 27V Sources and m anagement of resources at health facilities 34V I S ummary of co nclusions and recommendation s " " ' " . . 4 4

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" , '

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Volu.",e J . H ealth al/d E duca lion F mal/c lo l T racicm t Srudl- . S ummar \! o f O bs er va ti on s. C on ci' ll sr on s a nd R e commend ot lO n !

Acknc".,r)edgementsI This voJum e reflects the results of the health and education financial tracking studyunder taken by Pr icewaterhouseCoopersbetween December 1998 and February J999.The team from PricewaterbouseCoopers responsib le for th}s s tudy wishes to .express theirappreciatien to the m any individuah who. asststed w ith the w ork. P anicular thanks are dueto M r P L yimo (T reasury). M r A Msangi (T reasury). M r R Mukumbu (M inistry efH ealth).M r 0 M tey (M inistry of Regional Administration and Local Government) and M r MM achare (M inistry of Education and C ulture) for their kind assistance w ith our initialresearch, participation during the surveys and for inform ation and advice offeredth roughout th e s tudy .The consultancy was commissioned by the Government of the United Republic ofTanzania (G oT) and D epartm ent For International D evelopm ent (D FID ) of the B ritishGovernment. Howev er, th e v iew s an d recommen dation s exp ressed in th is repert are so lelythose of the consultancy team . and both G oT and D FID bear neither responsibility norcomm itm ent to this re ort.

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able 1.1- aSlc e IIcatlon S ares 0 t e e ucatlon sector pu IC resources:199~/95 1995/96 1996/97 1997/98

I

IIIctual Budeet Actual Budeet Actual Budeet

! GoT tot al r ecun -" en tand d ev el opmen t exp end it ur e'299.733 310.177 320.446 434.336

I383.184 479.485

I

IiIi ( jr an d t ot al c du ca ti on expend it ur e - TShs mi ll ion 79.165 84.776 79.098 91.515 95.467 106.947i i

ISpending on education as a % oftoul recurrent and I26.41% i 27.33% 24.68% 21.07%

I

24.91% 22.30%idcvelopment expenditure iBas ic education - TShs mi ll ion 49.174 I 54.298 51.602 59.197 I 68.895.

I Basic education - as a % of total IIII2.1% ! 64.0% 65.2% 64.7% I - 64.4%

~';".-

~"-.-,... - - . .- '1""0":', of O bs er va tI On s. C on clu sIOn s a nd R ec omm en da ti on s-._--

-. .,,=,roundJ :;8T recognises that concentrating its lim ited resources in prim ary education is likelyto produce the greatest social returns and econom ic gains; specifically, that high qualityprimary education contributes towards poverty reduction and promotes humand evelo pm en t. Since the m id-nineteen n ineties G oT's commitm en t to these goals has beend emon strated by substan tial a llo catio ns a s p erc en ta ge o f e du ca tio n sec to r re so urce s b ein gallo ca te d to b asic e du ca tio n (see T ab le 1 .1 ).

T B . d h f h d br

S ource: C nited R cpublic of Tanzania. P ublic Expenditure R cview July 1998 - Volumes I and II2 In addition to the GoT allocations to education specified above, over the past fewyears the secto r has con tinued to receiv e considerab le sup port from d ono rs. It is estim atedth at ac tu al d onor flows to educa tio n in 1996/9 7 to ta lled TSh s 12.7 b illio n 1 . Th is amoun ts to13.3%ofthe to ta l a ctu al expenditu re on educa tion.3 In the health sector, although GoT's policy is to shift priority to primary health care(PHC), recent data indicate that hospitals still receive a substantial share of the healthsector's resource envelope. Specifically, PHC services (delivered at health centres,d isp en sa rie s a nd d istric ts) w ere allo cate d 41% o f th e to ta l h ea lth b udge t (T Sh s 42.3 b illio n)for 1997 /98.4 However, "donors have been willing to fund salaries and running costs forpreventative and PHC services..2. In particular. a su rvey undertaken du ring the 1 997 /98P ub lic E xp enditu re R ev iew estim ate d th at in 1 996/9 7 donors a llo cated TSh s 12.8 b illio n to

1 A Survey of Donor Flows To Tanzania - 1996197 - 2000/01: T he C mted R ep ub lic of T an zania - P ub lic E xp en diture R ev iew . Ju l\" 1998(3 )


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. '..' :.~";S -. . . .' ./ .r ;. - t, t: :- r ( J I' .C r .. s. -. " .--> - '_4' . ._.~-

-. (vernm ent R eform Programme (LGRP). This m edium strategy~ c! principles including the need to:. .-. "\ -" '.,\0.1"... ; a> .. -- I" ... ~. -~" "_b..." -

.

instead enhance decision making at the local level so as to foster a fram eworkthat provides quicker and better responses to problems. Allied to this, "thedirectory of powers of central government vis-a-vis local councils will bere stric ted to lega l regu la tion w ith loca l governmen t's d ec is ions ,.6 .P romote loca l partic ip ation and inclu sion by c iv il socie ty .En su re that local authorities observe the tenets of good g overnance by ensuringth at th ere is fu ll a cc ounta bility an d tra nsp aren cy to th e p eople."B alan ce b etw een e qu ity and effic ie ncy " durin g th e reso urce allo ca tio n p ro ce ss'.

.

.11 A key reform under LGRP that is well underway is the enhancement of financialm anagem ent processes at local governm ent levels through increased autonom y over them anagem ent of resources and perform ance. A s of 1 July 1999, 35 "Phase I" Councils w illreceive block grants from central government. Block grants will be used to finance therecurrent costs of services (in health, education, agriculture, roads and w ater sectors).Grants will be conditional only to the extent that they will be dedicated t9 a particularserv ice. L ess em phasis w ill be placed o n the co ntrol of inp uts. In stead g reater focus w ill bep lac ed on meetin g p re-d eterm in ed m in imum sta nd ard s o f se rv ice .12 Initiative 2 - The second category of initiatives, Sector D evelopm ent Programmeshave also tried to address these problems by changing institutional frameworks for themanagement of service delivery units. For instance, the Health Sector Programme isprom oting closer accoun tability at service deliv ery u nits, in cluding th e establishm en t ofd istric t h ealth b oard s, lo cal c omm itte es an d th e d irec t c ha nn ellin g o f d onor fu nd s to serv ic edelivery units. In addition, m odalities are being put into place to increase efficiency inresource use and improve risk sharing. In this regard, it is expected that from I July 1999Go T will introduce 50 percent cost recovery with respect to drugs prescribed in districthospitals.13 Piloting w ith community funds is being tested in education. Specifically, a m atchinggrant prog ramme fo r prim ary scho ols has been design ed to increase enrolm ent, the qu alityof schooling and prom ote parental and community involvem ent in the mobilisation ofre sour ce s and monito ring s choo l perfo rmance.14 Initiative 3 - The M inistry of Finance is considering a m ajor shift in its expenditurefram ew ork. Th e m inistry reco gnises th at th e traditional system o f pub lic secto r fin an cialmanagement which concentrates on inputs does not lend itself as an effective tool for

~ Policy Paper on Local G overnm ent R eform , O ctober J 998:\ V ision For Local G overnm ent In Tanzania - A R ep on o n th e N atio na l C on fe re nc e o n "T ow ard s a S ha re d V isio n fo r L oc alG ov er nm en t i n T an za nia ", H el d a t t he Wh ile S an ds l Io te i ~ lav 1996(5 )


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VoL um e J -H ea ith a nd E dl/c atio n F ma nc io l T ro ck :n g S llId y. S lIm ma ,,' o fO bse "'o l/o n!. CO/'lc lu !lo n! a nd R ec omme nd atio n!

making inform ed spending decisions nor does it help public sector m anagers to focus onresuhs. .A .S G conseauence. it is difficult to m ake imDJem t:i!:ng al!encies throughout.. . .. - - -g ov ernmem acco un tab le fo r resu lts. In th e lig ht o f th ese co nstra~ms th e M in istry o f F ir.a nceis tak in g step s to impro ve fin an cial in te grity , p ro gram effic ie:1 cy an d e ffectiv en ess w ith inth e p ub lic sec tO r th ro ug h th e in tro du ctio n o f p erfo rman ce b ud getin g. It is an t)cip ated th atthis new fram ework w in emph:asise the im ponance of planning by ensuring tbat agenciesca n alig n b ud ge tary re so urce s w itb d esired o utc omes an d g oals.15 M any of the above initiatives m ay not bear significant outcom es unless the sy\tem sand m echanism s for the flow of funds betw een the centre (M inistry of Finance and donors)a re ra tio na lise d and s tre am lin ed to ensure e ffic ie ncy, tra nsp are ncy and fu ll a ccounta bilityof resources disbursed. In this context, there is a school of thought that leakage in thesystems of flow of funds from the centre to the service delivery points significantlyaccount for the apparent shortcom ings in value for m oney currently obtained from publicex pe nd itu re s o n ed ucatio n a nd h ealth . T his is th e su bjec t o f th is stu dy .T he financial tracking study16 This study has been commissioned against the above background. O ur Term s ofReference require us to:. Review previous studies of various budgetary formulae for the flow of,a llo ca tio n and con tro l o f re sourc es fo r p rima ry hea lth and educa tio n to d is tric ts .

App ra is e a lte rn ativ e fin an cia l managemen t, tra ck ing and aud it sy stems in cludingongoing w ork by the Local G overnm ent R eform Task Force and district basededuca tion! hea lt h suppo rt p rogrammes... Und erta ke su rv ey s at a d istrict an d se rv ice d eliv ery u nit le vel an d ascertain th eira bility to adequate ly s pend and con tro l re sourc es .

A scertain the degree to w hich guidelines developed and issued from the centreimpact o n d ec isio n mak in g a t a lo cal lev el... E sta blish d iscre pan cies b etw een allo catio ns a nd a ctu al e xp en ditu res, an d th eircauses.. A ppraise the usefulness of financial reports particularly in assisting in theidentif ication of discrepancies.

C on du ct an in stitu tio na l assessmen t w ith a v iew to id en tify in g ca pacity b uild in gneeds in a re as re la tin g to fin an cia l p la nn ing, tra ck ing and aud it... Recommend any actions needed to ensure allocation and expenditureconsistency. ,.

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; ' lU':" aallOn5

, j methodology

. Identified the various m echanism s for allocating and channelling funds forprimary education and health. In addition, we interviewed a number ofstakeh olders (in g overnm ent, d ono rs and NGO s) and w here available co llectedd isbursement data.. Developed survey instrum ents, which we used to track resources disbursedunder the various m echanism s to sam ple districts and service delivery units, Inaddition, in the sample districts we undertook an evaluation of financialmanagement sys tems and in stitu tiona l c apac ity .18 Our survey scope was lim ited to three districts Kiteto, Kondoa and Hai, which areresp ectiv ely lo cated in A ru sh a, Dodoma and K ilim an jaro re gio ns. T hree fac to rs in flu en ced

our decision to select those districts. First all three districts are included in thegov ernment's o ngoin g L oc al Gov ernmen t R efo rm P rogramme.19 The second factor was accessibility. The three regions share borders. Kondoa andK iteto are only 130 km apart. The distance betw een the tw o districts and A rusha is longer(300 km) but s till manageab le . This fa cilita ted bette r co-o rd ination o f our enumera to rs.20 The third factor is that they vary in term s of econ'om ic circumstance, geographicalarea and p opulatio n. H ai D istrict is con sidered th e m ost w ell off economically. Whilst H aiD istrict's geographical area of 2,168 square kilom etres is sm aller than the other tw o, itsfairly densely pop ulated w ith an estim ated 24 0,00 0 in hab itan ts. O n th e other h an d K iteto arelatively new district is the poorest one in our sample. Kiteto is also vast covering ageographical area of 16,865 square kilom etres, and sparsely populated with 120,000inhabitants. Kondoa's economic wealth is somewhere in between the other two. It has4 00 .0 00 in hab itan ts sp re ad ove r a g eogra ph ica l a rea o f 1 3,2 00 square k ilome tre s.21 On the basis of om analysis of the results of the survey in the three districts, we havem ade generalised obser\'ations and conclusions concerning the order of m agnitude andtrends in the flow s and m anagem ent of fin ancial resources to districts an d service deliveryunits. W e wish to em phasise that our sam ple of districts and service delivery units is notstatistically representative. Therefore, our observations and conclusions do not havestatistic m erit. Nevertheless, as conceived at the tim e of the survey design the sam plecoverage provides a broad fram ework for deducing the order of m agnitude of problem sand issues in the flow and m anagem ent of resources to districts and service delivery unitsin general .Organisation of the report22 W e present our report in two volumes:

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flo!"",., J . H ealth and E duc otlC " F mon clol T ro ck mv . Study . S um ma ry o[O bserw J//o ns. C onc lusio ns and R ec om me ruiotio ns

. Volurne 1 - A S:;mn:a :,}'of Observa tions , Conclus ions and Recommendat ions.

. \".oluliJe 2 - S1:~\,9~), Res:.:l::.

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.'~I T ra ck in g S tu dy . S umma ry o fO bserv a/lo ns. C on clu sI On s a nd R eco mm en da tio ns

I .: .:~~ j :'sourseo lrom central government and'~;(""~.;r+ ~ouncils

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23 Our review of the system s and procedures for the flow .of resources from the centre(MoF an d d on ors) rev ealed th at th ere a re fo ur mech an ism s u sed fo r d isb ursing fu nds:

.Mechanism 1 - Subventions to district councils to m eet recurrent expenditurew ith re sp ect to activ ities in th e p rim ary e du ca tio n, h ealth, roa d a nd wate r se cto rs.M echanism 2 - Amounts disbursed for developm ent expenditure (constructionand rehabilitation of health and school facilities). D isbursements fordevelopment expenditure are channelled to districts via the RegionalAdministrative Secretar iat.

.

Mechanisms 3a and 3b - D isbursem ents to the M inistry of Education andCulture (M oEC) and M inistry of Health (l\:loH ) respectively for centrallyprocured goods (e.g. examination papers, drugs and vaccines) which aresubsequen tly d is tr ibut ed to d is tr ic ts .-~J'\. . Mechanism 4 - D isbursem ents m ade by donors via the tw o m inistries for a total,~''f.j' ci\ ...,:,.,;1: of fifteen m ajor program mes.',-,-w'" ',:::-,'3 24 \Ve set out the resulting data on disbursem ents under the various m echanism s above:'L-Sk-."()in Table 2.1. In the remainder of this section, we describe the key features of eachmechanism.

.

i\lechanism 1 - Subventions for recurrent expenditure25 From the inform ation that \ve have been able to collect so far, subventions to districtcouncils are by far the highest am ount received under the four m echanism s describedabove (see Table 2.1). Subventions to district councils are classified as "protectedexpenditu re ". Spe cific ally , th e T re asu ry h as underta ken to ensure th at budge te d a llo ca tio nsto district councils and approved by the N ational A ssem bly are released in full and not onth e c as h budge t b asis which is a pp lie d to m in is trie s aRd regiona l-e stimate s!!.

M 'Ille government has been endeavouring to a.:hieve fiscal discipline through the introduction of a .:ash budget system. O ne of theram il1cations of this is that disbursem ents bear little relation to voted expenditure. Cnder the next tw o m echanism s therefore. w e haven ot an alvscd disbursem ents ag ainst bud gets in m uch detail.

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FiA:mciaJ "ear end rrShs '0(0)31.12.96 I 31.12.97 I 3J.12.98 30.06.97 I 30.06.98 30.06.99'

~ kc lta nis m 1 - Subventions 0 I 0 0 84.152.034 10\.165.020 43.414.720,\ -I e :hani sm 2 - Do:velopment 0 0 0 12.142 762.185 0

; ~xpo:nditure I0

~ !. :c ha ni sm 3 01 - Education. 0 0 0 400,000I

424.046 457.410C~n tr al l\' n ro cu ro :d 2 00 ds I

~ k .: ha ni sm 3 - Ik al th . 0 I 0I

0 4.500.000 7.440,000 4.000.000C cn tr all \' p ro cu re d I%oo ds .. I~ Ic ch a ni sm 4 - Donor 0 680,472 936.095 3,691,560 4.138.749 566.825

p rO l !T amme s i n Educ at io nii \t.:chan ism 4 - Donor 971,739 1.263,073 .,215.169 5,094,791 2,548,011 4.104.224i

~o l!Tammes in Hca lt h ll

IiI 1.943.545 2.151.264 97.850.527Tolal 971.739 116.478.011 52.543.179

VoZ ;; in iI . H ea jlh a~ ii E du ca /l.o n F in an cI al T ra ckmf ! S lu d) ,: . S umma, ,: ,' O rO bSC"W11IClI !, C o nc lu si on ! a nd R ec omm en da llo ns

26 In 1996/9i, 1 99 7/9 8 2 nd 1 99 8/9 9 b ud gete d su bv en :io r.s 1 0 a ll d is~ :-icts in T an zan iaamoumed 10 TShs 81.993 m il!ion, TSb~ H,38: m iHion and TShs 104,560 m illionrespectively.T ..blc 2.1 - D isbursem ents m ade undcr four m echanism s

S ou rce: ~!in istry of F inan ce. S ector ~ Iinistries an d D on ors27 In Table 2.2 below we provide an analysis of resources allocated to the health anded uca tio n sec to rs u nd er b ud ge ted su bv en tio ns in 1 99 6/9 7, 1 99 7/9 8 an d I 9 98 /9 9.

9 Data provided covers the period from I July 1998 to 31 D ecember 1998.10 Excludes Shinvanga R egion data for 19% /97 and Iringa R egion data for 1997/98, as appropriation accounts could not be found.II D ata lor tho: v ear ended 31 D ecem ber 1996 for one program me in the health sector w as not available at the tim e of w riting this repon

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V ol...",e I- H eal:h a nd E du cal1 0n F man clol Tra ckm l! S lud v. S um mo n' o (O bse,-vollom , C on ciuS lon S'a nd R eco mm en da tIO n!

30 The data on disbursem em s that w e co!!ected during this stU dy j ndica!e that aggregatesubvemions were funded in full for the fina:1cid yea:-s ] 996/97 and 1997/98;3. In factam ou nts disbursed w ere higher th~ n bucketed amoun ts by 2 .7c;,oand] 3.5% in 19 96/97 and1997/98 respectively (rete~ 10 Table 2~})1';. Treasury provided for this higher level offunding by issuing reaHocalion warrams from unutihsed ministerial supply votes toRegional Admin is tr at ive Secre ta ri at s' vo tes.l\1echanism 2 - D ev elo pm en t ex pen ditu re31 For development expenditure (Mechanism 2), which is disbursed via RegionalA dm inistrative Secretariats, less than 50% o f bu dgeted allocation s fo r local gov ernmentp ro je cts we re funded in both 1996/97 and 1997/98 . In panicu la r, ou t of budget a llocationsamounting to TShs 1] 2 million and TShs 1,920 million in ] 996/97 and] 997/98respectively, only 10% and 40% of the budget was funded in each year. Althoughdisb ursem ents in 199 7/98 w ere w ell below b udget estim ates, they represented a d ram aticin cre as e ove r th e p revious yea r's d is bu rs ements .M echanism 3a - Education - C en trally p rocu red g ood s32 District councils also receive allocations of centrally procured goods (in-kindcontributions) from the social sector m inistries. For primary education the Treasuryallocated around TShs 400 m illion each year to M oEC (M echanism 3). M oEC disbursedamounts to the National Examinations Council (NEC) as a subventjon. 1\TEC usedsubv en tio ns to se t, mod erate, p rin t an d d istrib ute, m ark a nd p ro cess ex am in atio n p ap ers. In1 997/9 8 and 1998/9 9 NEC :

.Produced 1.7 million and 1.4 million Standard VII examination papersresp ectiv ely a t a c ost o fTSh s 146 m illio n a nd TSh s 156 m illio n re sp ectiv ely .Arranged for the distribution of papers to Regional Education Officersthrou!Zhout Tanzania at a cost of TShs 77 million and TShs 43 millionrespe~tively 15.The re afte r, R eg iona l Educa tion O ffic ers a llo ca ted and d is tributedpapers to their respective district councils. Allocations were based onregistration data (on th e number of cand idates to sit for exam ination ) co llectedfrom schoo ls p rio r to p rin ting.

.

I] The nex't section provide a m ore detailed analysis of disbursem ents against budget by region and for the three districts included in thesurvey14 Amou nt s d is bu rs ed a re li ke ly t o h av e b ee n h ig he r t ha n a pp ro ve d e st im at es b ec au se t he J ul y s ala ry awa rd s a re n ot i nc lu de d i n th ehudget15 W e h av e n ot a s v et b ee n a ble to o hta in a b re ak do wn o fN EC 's e xp en ditu re o n p rim arv e du ca tio n fo r 1 99 61 97

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a)c , - na "SIS 0 0 IS urscmcnts to Istnct counci s an oSPlta s or ru gs an d sU I)lJlic!I(TShs ' lIC it )) 1996/97 199719R 1998/99'.! :.891,037I

4,037.820 1,570.090i D ru g k its t(,r h~ alth ~~ ntr~ snd d isp ensariesI

I

I 3,925,479 4,868,000 1,819.000I Drugs and mcdical suppli~ s for regional and district hospitalsi I TS h s m il li


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'"~ 'o lu me J -Heal ln a nd Ea -u cal lo r . .C 'monc /Q i7 !"d ti ff n1 ! S lu li y - S umm c' V o fO b ~e rv o/l on ~, C on ci :'! lo n~ o nd "R ec omm en dO ll on s

Mec:hanism 4 - Donor programme disbursements iB educarioB andbea I th36 During the financial tracking study we also undertook a survey of alternativefi.nancial m anagem ent, tracking and audit system s used by donors (M echanism 4), W elooked at nine programmes it} the heahh sector and six programmes in the educationsector. Programmes are run centrally by the health and education m inistries and havev ariety o f ob jectiv es a s shown in T ab le 2 .4 below ,

Healtll Child Surv ivalProt ec ti on andD evelo m emTan za nia Foo d a ndNutritionNationallmmunisationDavsNa tiona l A id s Contr ol

P rima ry Health Ca reServicesNat ional Tuberculosisand LeprosyP ro ra rnmePharmaceuticalSupportExp an de d P ro gr .u nmeon lmmun is at ion

Communi ty Heal thFund

. Con trib ute to a ch ie vin g th e c ou ntry p ro gramme goa l o fr ed uc ed mon ality b y impro vin g th e q ua lity a nd u tilis atio n o fb as ic h ea lth s erv ic es fo r c hild re n a nd women. Ad\'is e g ov ernme nt o n a ll m atter s p en ain in g to fo odDis sem inate f ood and nutr itio n in fonnat ion to th e pub licCon du ct re se arc h in m atte rs r ela tin to fo od a nd n utr itio nE ra dic ate p olio b y th e Yea r 2 00 0

.... Con tr ol th e s pre ad o f A IDS by: p ro vid in g e xte nd edi nf ormat ion; p romoti ng a mu lti s ec to ra l a pp ro ach invo lv ingm in is trie s, NGOs a nd c ommun itie s; a nd e ns urin g th atre so ur ce s a re c han ne lled to re io na l an d d is tric t le velsDecent ra li sc hcalthcare expenditure

. Con trib ute towa rd tllC impro veme nt o f h ealth a nd th c wellb ein g o f th e n atio n b y red ucing th e o ccurren ce o f TB andle pro sy c as es u ntil th ey a re n o lo ng er a p ub lic h ea lth p ro blemEns ure c on sta nt a va ila bility o f d ru gs a nd med ic al s up plies inpublic heal th faci li ties1m rove har rn ac eu tic al s er vi ce s c ount rvw ideReduce chil dhood mo rb id ity a nd mo rt alit y th rough t hep ro \'ision of v accin es against the six immun isable diseases -Tube rc ulo si s. Meas le s. Po lio , T eta nu s, Whoop ing Cough andD i h th eriaS tar t a p rep aymem s ch eme th at wou ld e na ble th e ru ra lp op ula tio n to h av e g re ate r s ec urity o f a cc es s to h ea lth c areEmpowe r h ou se ho ld s a nd c ommun itie s in h ea lth c aredecisions

...

... Promote c os t sha ring w ith s tr ong lo ca l p ar tic ip at ionP ro vid e a s tim ulu s to lo ca l h ea lth ca re ro vid ers

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. Plan and co-ordinatethe provisionof educationalmaterialstoBook Management schools and colleges. Ensurethat the quality of educationalmaterialsmeetsexoected s tandards. P romote c onditio ns whic h wou ld e na ble th e gov ernmen t toInternational

P ro gramme fo r th e p rogr es sively r egul at e. r es tr ic t and p roh ib it c hil d l abour w it hi E lim inat ion o f Ch ild a v iew to b rin gin g a bout o bse rv an ce o f In te rn atio na l L abou rI Organ isa tio n sta nd ard s on m in imum age a dm is sio n toI LabourI em ploym ent and w ork"! . Imp rove qua lity a nd a cc es s to p rimary e du ca tio n' District Based Support . Improveperformanceof district education.staff. teachers andI to Primary Educat ioni pupi ls i n t ar ge ted d is tr ic ts th rough suppo rt ing quali tyI interventions. ImproveprimaryschoolenrolmentratesChild Survival . I nc re as e p rima ry s choo l comp le tion r at esProtection and

DevelopmentCommunity Education . Increase enrolm ent quality of schooling and parental andcommun ity in vo lvemen t in m onitorin g sch oo l p erform an ce

I Fund

. :- ';'~:::-2;jon

" "' ~ "

. . - ~: :! ' S IU ~\I ' S umma ry o [O bs eM la lio ns. C on clu sio ns a nd R ec omme nd allo ns

i-ro ram m e nam e:Edu ca tio n Co - . Decentn ll is e the s el ec ti on and p rocu remen t o f educa tionalmate ri al s to d is tr ic ts ! s choolsordirunion,. ~._,~ ,~_ .~.~. ~~',:""''''C\'~ :" '.h \" ~i.::a ] f ac iJ jtje~ a r ~ e!e c~ -;~ t'r 1m 2~ ' ~('~yv,!~-.' h.'_ '-- _u- "-"""-"--'~'~.~.' ~--

37 The institutional and administrative arrangements with respect to programmes inh ealth and educa tio n are fa irly sim ila r. We desc rib e th em in b rie f as fo llows:. Nine out of fourteen of these programmes have set-up special units (based inm inistries) to ru n th e initiatives. B etw een 1 January 199 6 and 31 D ecember 199 8such pro grammes spent an estim ated T Shs 1 billion o n lo cal cost compensationon p ro gramme sta ff salarie s (see T ab le 2 .5 ).

The C hild Survival Protection and D evelopm ent Programme is adm inisteredcen trally by a special u nit at UNICEF... All programmes except the Expanded Immunisation Programme maintainspecial accounts with commercial banks. Donor (DANIDA) funds for theE xpand ed Immunisation Programme are ch ann elled throu gh the Treasu ry. Th eTreasury inform s M oH that funds are available by issuing a W arrant of Fundsand Exchequer Issue in the same way as it. does for disbursements frominterna lly generated revenues .

M ost programmes maintain fairly simple manual accounting systems. Forinstance:.

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Volume 1 -Health and Educa/lon Financlo! TrocklflR StutJ.v - Sum ma~' ofO bJenlal/ons. C onclusIons and Recom merl/:Jo/ions

The N ational A ids CORtrol Programme m aintains a sim ple receipts andp aymems bookk ee pin g s ystem . In a dd itio n p ro gramme per~ onne~ma in ta in asim ple cash book for each donor to enable tnem to report on receipts andutilisatio n o n a do nor by d on or b asis.Sim ilarly, the B ook Managem ent U nit u~s a spreadsheet package to recordcash receipts and payments. Spreadsheet data are extracted m onthly,qua rt erl y cmdannua lly and u sed in r eport p repa ra tion.. Oth er p ro grammes u se more sop histicated acco un tin g system s to re cord , co ntrol

and report on resources received and expended. For exam ple, The N ationalTuberculosis and Leprosy Programme is in the process of com puterising itsaccounting system . A n off the shelf package "P latinum " has been procured. It isan ticip ated th at th e new sy stem w ill comp rise a flex ib le rep ort w riter to meet th erequirements of MoH as well as those of various donors supporting theprogramme. T his package is being introduced to all governm ent departm ents asth e s tandard governmen t a ccounti ng sys tem.

38 Ten (67% ) of the programmes surveyed have disbursed funds and/or in-kindcontributions to districts over the last three years. O ut of the TShs 15.2 billion and TShs10.0 billion disbursed (betw een 1 January 1996 and 31 D ecem ber 1998) under the abovep ro grammes in h ealth an d edu cation resp ectiv ely , lo cal co uncils receiv ed cash worth T Sh s5 .7 b illio n. In a dd itio n lo ca l c ounc ils re ce iv ed in -k in d c on trib utio ns (e .g . d ru gs , v ac cin es,e du ca tio na l ma te ria ls e tc .) wo rth TSh s 10.9 b illio n (re fe r to T ab le 2 .5 ).

--:,"-"""

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Volume / -Heal,h and Educallon FinancIal Tracking S,udy -S umma ry o fO bse rv allo n:s. C on clu sIo ns a nd R ~comm en do lio ns

III Sources and mana2ement of resources at district"-councilsIntroduction39 The objectives of the survey of sources and management of resources at districtco uncils w ere to ascertain the p otential sources of rev en ue available to district coun cils;and exam ine control system s in place to safeguard the utilisation of, accounting for andaccountability over resources. In this section we set out the key survey findings(high ligh ted in italics) under four headings:

Potent ia l sources of revenue.U til is ation of funds .Accounting fo r f unds .Accountability.

In addition w e set o ut recommend ation s to resolve key issues in bo ld and italics.0Po tential so urces of rev en ue41 Our survey results indicate that district councils in addition to revenue from theirown sourc es h av e fo ur p ote ntia l so urce s o f rev enue: g ov ernmen t su bv en tio ns; d ev elo pmen texpend iture; donor con tr ibu tions; and paren ta l con tr ibu tions.Gove rnmen t subventions42 Subventions from central government constitute the major source of funding forprim ary health and education in districts. Our survey results show that such funds weredeposited in each district's m iscellaneous or deposit account. W e further noted that assubventions were deposited in aggregate to cover the four priority sectors (health,education, roads and water), the most common practice was to transfer personnelexpenditu re a llo ca tions and o ther cha rge a llo ca tions to th e re levant s ec to r a ccounts .43 On the basis of our sample survey, we confirmed that m onthly subven tions w eredisbursed to d istrict councils in fu//. However, we noted one instance over a six monthperiod where disbursements made were understated by 0.8% (refer to Volume II - TablesA l and A2). Howev er w e consid er th at th is u nd erstatemen t is immate rial.Deve lopment expendi tu re44 The survey revealed tha t go vernm ent disb ursem ents for d evelopm ent exp en diture tod is tr ic ts a re in te rm ittent. The districts covered by the survey did not receive anydevelopment funds in financial year 1996/97. In 1997/98 councils received amountsranging between TShs 4 million and TShs 7.4 million. However funds disbursed in1997/98 were received towards the end of the financial year. A t the time of the survey no

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.. ', ,,,a ') ' o .( Ob se rv al lo ns . C on clu si on s a nd R ec omm en da lio ns

.~ . ... .. .' .'''''". . .. C)~, ~ ..;~ m em planS. :=\gamst tnIS :m :;r.g w e recu:.

!' 01'('' '. '' ' '1 (>!1r should make m".'(' n",..di(~t{Jble h. . co"r,.;,1:u':'"'''' ~ d'ri:::

45 It is also significant that councils w ere not aw are and M inistry of Finance could notclarify if there is any objective criteria in the allocation of these funds betw een differentcou ncils. In this conte.:"t therefore w e recommend that the 1\.1inistryof F inance shouldhav e transpa rent and obje ctl1 'e c rite ria fo r th e a llo ca tio n o f d ev elopmen t fu nd s.Donor disbursements46 In addition to subven tions, donor contributions (from the cen tre combined w ith directdonor disbursem ents) were the next m ajor revenue source. The results of the surveyindica te tha t:

.D irect contributions from donors. NGO s and charitable organisations foreducation and health to districts constitute on average 63% and 33%r es pe ctiv ely o f o th er cha rg es d is bu rs ed by c en tra l gov ernmen t.Donor cOlllributions from the cel1lre for education and health on averageconstilllte 55% and 51 % q f o th er cha rg es d is bu rs ed by c en tr al gov er nmelll.

.

47 However we noted that direct donor colllributions appeared to favour better offdistricts. In particular. th e poorest district from the survey had the sm allest contributionfrom donors. B etw een 1996 and 1998 the poorest district su rveyed received as little as 1%and 9% indirect and direct donor support to health as a percentage of other chargesdisbursed b y central governm ent. In view of the donors' commitment to combatingpoverty they should collaborate between themselves and GoT to ensure that theeconomical( v wor.'ieo ff d is tr ic ts a re prio rit y benef ic ia ri es o f their con tr ibut ions .Parenta l cont ribu tions48 For most districts the Universal P rim ary E du cation (UPE ) levy is the only cha rge bydistrict cOllncils OIlparel lls. In th is resp ec t d istrict co un cils, su rv ey ed o n a vera ge re ta in ed57 % of C PE contributions. O n average U PE retained by the district councils am ounted to2 9% o f g ov ernment su bv en tio ns fo r o th er ch arg es.49 In one of the districts covered by the survey however w e found a sports levy, w hichevery pupil pays to the council through the schools. This levy was about TShs 1,500 perpupil, \vhich is 50% higher than the UPE levy.50 The MoEC policy is that beginning 1 January 1997 councils should nO! take anyparental contributions, especially from the lJPE levy. and that contributions should beretained at schools. However, this policy directive has been ignored by most if not alldistrict councils .51 The councils do not appear to recognise the authority of MoEC. However theyrec og nise th e au th ority o f th e M in istry o f R eg io nal Adm in istratio n an d Local Gov ernmen t

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Table3.2- ontributlO n to ow n sources v revenue catCl!orv:. .1... Ave ra~ cc oritrib utjo n to to ta l d is trictl'e vc nu ee ven ue ca tc 20 rv ..

Rate s a nd T ax es I ~~%Cess I 18%Licences 6%Fecs 22%Fines 1%

i Use r c haqr es 4'Yo, Propenv sal es 3%Investment 1%

i Miscellaneous 1%;, Total 100%

I'o l..m e J . H ea lth an d E ducatIo n Flna ncla! Tra ckm 9 Stud y. Su mm ary' o fO bservollo fls, C on clu sIO ns aM Recom ",en da llon s

(MRALG), T herefo re we recommend that l\loEC with clear support from JHRALGclarifies am i ensures com pliance w iriiitJ policy m l parental JeJ'ies w ith respect to twoaspects:. Reite ratin g th at UPE lev ies a re to b e retain ed in s.ch oo l~ .

Specifying, what proportion of spons or any other levy should be rem itted byschools to th e counc ils ..

C ouncils' ow n revenues allocated to education and health52 the survey resulrs show that councils' ow n revenue resources constitute on average18% o flO la l s ub ventio ns and own re sour ce s (se e Tab le 3 .1 ).

; Re\'enuesourceSubven tions for nditure 76%S ub ven tio ns fo r oth er ch ar es 6%

; Cou nc ils' o \\'n re ven ue s 18%; To ta l subvcnt ions a nd own r esou rc es 100%S ou rc e: V olume I I. T ab le s A 1.1 a nd B1.253 Nearly half of those revenues are collected from taxes and user charges (see Table3.2).

C b

Source: Volume 11. Tables AU and BI.2

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. -, , districts covered by the survey do the councils use any of their own...;"" rH1dhealth activities. This resu lt is co nsiste nt ~ ~th a p rev io us"

~. .ocalco un cu s a na the ir re aso nab ie ne s~ . h owev er, lh e fa ct lh at loc ai c oun cu s n av e resp on slDHuyfor the delivery of several other services (e.g. community developm ent and agriculturalextension services) which are not funded by central government is likely to result ina dd itio na l d emands fo r th e lim ite d re sourc es ava ila ble .

. 56 Nevertheless it has come to the knowledge of the survey team that some districts inO ther parts of the country are m aking significant contributions to education and healthfin an cing, a nd e sp ec ia lly in p romoting and suppo rtin g commun ity in itia tiv es. In the spirit(~f supporting sw.tainahle social and economic development, councils should beencouraged to earmark a proportion of their own revenue sources to supportprogrammes in health and education.U tilisatio n of su bve ntio ns57 The Ministry of Finance disburses funds to districts on a monthly basis.D isbursem ents are m ade in tw o tranches, one to m eet personnel expenditure and the otherfor other charges. Each tranche is aggregated to cover the education, health, w ater androads sec tors .S ub ven tio ns to meet p erso nn el ex pen ditu re58 Subventions for personnel expenditure are based on the payroll, which isadmin istered at th e c en tre. T he M in istry o f F in an ce tran sfers amounts to co un cils b ased o nthe p ayro ll. T he c ou ncil in -tu rn mak es cash pa ymen ts to emplo yees.59 The survey revealed th e level o f un co llected sa la ries in d istricts, a s a p erce 11 /ag e o fp erso lllle l exp en diture is low. In particular, on average the level of uncollected salaries(over a six m onth period) as a percentage of personnel expenditure disbursed w as 0.24%(refer to Volume 11T ab le A1.3 ).60 It is however significant th at u nd er a c ash p ayro ll system the re is co nsid era ble sc op efor payilll! ghost w orkers. T his has previously been confirm ed under the C ivil ServiceReform Programme. A lthough the C ivil Service D epartm ent has over the last four yearssu sta in ed e ffo rts a nd a ch ie ved positiv e re su lts w ith re ga rd to con tro l o f p ers onne l numbers,expenditures and the elim ination of ghost workers, this problem has by no m eans been

I 0 D .:c~ nlralisalion o f E du catio n an d the R ole o f Ed ucation M an ag ers in T an zan ia - J.C.). Galabawa.October1993

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V olu me I- H ea l;h o nd E du cotlol'! F ina ncIa l Tra ckin g S:ud v -S ummo1 ".' o fO bs erWJ ll on s Con cl uS io ns a nd R ec omm en do l,o ns

rem oved]8. In fact this is going to be a continuous chaIJenge for personnel expenditurec om ro ls bOth a t th e c em re ~ nd a . d isu ict co un ciis.61 The im plication of this is that \vith the current cash based system for salary paym entsthe risk of diversion to pay ghoSt w orkers w iU rem ain. The problem could get w orse w henthe councils assum e responsibility of the payroll unless effective payron system s areimp lemen ted]9. In this r egard ther efor e it is imperativ e that:

Councils move towards a bank-based system for the payment of salaries tom in im ise ca ses o f fra ud. Steps are taken to ensure that the in ternal controls for perso nnel e.xpenditurea re not u nderm ined durin g the p rocess of decentralisation of the payroll.

62 Evidence from the survey suggests that most teachers and health w orkers are paidon tim e. S pecifically the averag e percentage of employees that receive their salaries ontim e in ed uc atio n an d h ea lth are 5 9% and 6 4% resp ectiv ely .63 How ever in districts w hich cover large geographical areas, personnel em ployed atstations aw ay from the district councils tend to experience delays in receiving paym ent.Our survey data show s that 011average sllch personnel spend up to three days a m onthchas ing salar ies . Further, in extreme cases personnel can spend up to ten days a monthchasing salaries. M easures should be introduced to m inim ise tlelays in paying salariesand avo id wast ing 1 'a luab le resources .

.

64 T he survey results also ind icate that 50.3% of em ployees in the educa tion and healths ec to rs hav e o llts ta nd ing sala ry a rr ea rs . On averag e salary arrears per em ployee are T Shs5 8,9 54 . A rrears p rim arily re la te to p romo tio ns (4 3% ), tran sfer ex pe nses (2 9% ) an d u np aidlea ve (1 3% ). A cc ord in g to th e M in istry o f R eg io nal Adm in istratio n an d Local Gov ernmen tdistrict councils throughout T anzania have on at least tw o occasions subm itted reports onarrears to the centre. H ow ever, to-date arrears do no t app ear to have been paid .65 This is a serious problem not just for teachers and health workers. In the 1998/99budget GoT has provided for salary arrears paym ents w orth TShs 10 billion in the civilcontingency fu nd. S ince teachers and h ealth w orkers constitute about 50% of th e payrollthe am ount in arrears could be as m uch as TShs 2.5 billion. In this context therefore, werecommend th at g ov ernmen t in stitu te m ea su re s to elim in ate cu rren t a rrea rs.

I S T he on gO ing P ers on nel C ontro ls an d Info rm ation S ystem s P ro ject has recen tly co mpiled an interim p erso nn el and p ayroll d atab as ew hich eontam s thirteen core data item s. The database is expected to provide useful m anagem ent inform ation on personnel that w asrrev io usly no t availab le. H ow ev er this ben efit m ay no t e:\1 end to d istrict co un cils w hen d ecentralisation tak es p lace.9 W e understand from the Local G overnm ent Reform team that in order to m aintain a reasonable level of control during the transitionperiod co un cil w ill co ntinu e to u tilise cen tral p avro ll p reparation on a b ureau typ e b asis .

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25/48

87% 13%32% 68%57% 43% ",-;K;' .59% 41% /~ () u J43% 57% I17% 83%7% 93%

, 12% 88(J!o12% 88%

. :;,..C,"..,~-

, .' -"",ary ofObservalions. Conclusions and Recommenda tions

'. P' " u..~H aM. m am lenance expenditure (other charges)Governm ent provides subventions to m eet other charges for the four priority sectors.

- . .' .: -: ,: ,: -~mer .t ~!2.T 'Jning DersDective the hi!.!hest amounts gO to education-.. . -"" - ......... . iollow ed by health (24% ). H ow ever, the survey indicates that once the funds areu~rv~1Ied in the coffers of the district councils the m atter of priority sectors is forgotten.This is partly due to the fact that the Treasury rarely provides a breakdown of howd is bu rs ements fo r o th er c ha rg es s hould b e a llo ca te d.67 During the survey we estim ated the proportions of subventions for other chargeswhich were due to health and education items if councils were to allocate the fundsa cc ord in g to th e p rio ritie s re fle cte d in th e n atio na l b udge t. The resu lts o f the su rvey su gg esta sig nific an t d iversion o ffim dsfrom th e p rio rity sectors a nd items (se e T ab le 3 .3 ).68 O n an overall basis the survey suggests that:

.In educa tio n about 41% of the fim ds due for other charges are diverted and asm uch as 57% o n a weig hted a vera ge b asis.In health on an overall and w eighted average basis about 88% of the fim ds duefo r o the r cha rges a re diverted .

.

Tablc 3.3 - The extcnt to w hich disbursem ents for othcr char"cs are divcrtcd to othcr usesEducation ..i.School matcr ia lsCateringExamina ti on expensesO\ 'c ral l a \' cra t!e

. .. ... .. .f'f?fd~~allo~~~i~nactuitU~K%o:?:ff~n~s p~s.si~ l~:di"c rtcd '"

H/soent "H'''' . ..:" ... ..H ..':

Wci !!ht cd a \' er a2eHcalth'Hospital suppliesHospi ta l d ic tO"c ra ll a \' cr a"c

:.

Wei2htc d a ,'c ra 2eS ou rc~: \'o lum ~ II. T able A !.669 This resu lt is co nsisten t w ith th e resu lts from :. T he audits of donor programmes described in the previous section (m echanism4) in which the diversion of funds was reported in 4 programmes (26% of the

programme surveyed).

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V olu me 1 - H eallh an d E du cario r: F mer. :! T ra ck in g S IU QV -S umma ry o (O bse rv allo 1lS . C on clu sIo ns a nd R ec omm~ nd allo ns

A previous study, w hich found that "som e education gram s, especiaH y the percapita gram s, are diven ed to o ther no n-educatio nal expenditu res,,2 o. O ne of thereasons that h as been given for no n-compliance is that "there .are n o incentivesfor efficiem use of grants nor are there disincentives for inefficient users".H ow ever, ar:other reason for non-com pltance m ay be that councils require there sour ce s to mee t o ther oblig ations .

70 W ith respect to the possible diversion highlighted above there is need for betterguidance from the centre on how to prioritise other charges. Under the ongoing LocalGovernment Finance Reform Project there is a proposal that the M inistry of Financedisburses block grants via a special account adm inistered by the M inistry of RegionalA dm inistration and Local G overnm en t (MRALG ). So far a fram ew ork h as b een d evelopedthat outlines disbursement and monitoring processes. To compliment this effort, were commend th at:

.

. In fo rmatio n requirements amlflows b etw ee n m in istrie s a nd to d istric t c ouncilsa nd mon ito rin g a rra ng emen ts a re sp ec ifie d. This in clude s f or example :

T he documentatio n to b e p ro vid ed to d istric ts to e nsu re th at th ey und ersta ndw hat d isbursem en ts relate to. In th is respect w e no ted earlier in this sectionthat current documentation used by the Treasury to notify AccountingOfficers of fund releases is not com prehensive enough. W e believe thatmore detailed information should be generated to support eachd isb ursemen t. S uch in fo rmatio n shou ld sp ecify : th e sec to r-g ran t c ateg ory ;amount to be disbursed; and details of cumulative disbursements. Thisin fo rmatio n wou ld a lso b e o f u se to se cto r m in istrie sThe reports to be generated by MRALG . For instance we understand thatMRALG w ill have the pow er to w ithhold disbursem ents to districts if theyfail to com ply w ith laid out procedures. To p romo te good ca sh flowmanagem ent and transparency, it w ill be im portant that MRALG keepsth e Trea su ry info rm ed of an y b ala nces resulting from fum ls w ith h e ltl.

In-kind contributions from the centre71 Regarding textbooks, we confirmed that there were no significant holdings ofin vento ry in d is tr ic t counc il s to re s. We found that m ost textbooks had been distributed toschools. W e noted that the only textbooks that had not been distributed w ere outdated dueto changes in the curriculum . W e also found som e drugs in the district stores which hadexpired. Our findings suggest that there are no significalll incidences of poor storage oru tilisa tio n o f w ha t is rec eiv ed in k in d.

cO D ~cen tralis atio n of E du catio n an d the R ole o f E du catio n M an agers in T an zania - lC .J. G ala ba wa . O cto be r 1 99 3

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27/48

.',U::..a.iV'."'U~" -

. f'xpenditure

. ..

...2... ..i./:;D ursem ents for developm ent expendilllJ:e reach district:.:~,ui.~D ursemem s appear to be used for their intended purpose, which is to. ., ' :~'1d healthfaci/ities.Accounting and accountability for funds73 The su rv ey co nfirm ed th at most d is tr ic t counc ils :. Are not k eeping comple te re co rd s o f th eir transa ctio ns. In thi s r egard:

C ash books for exam ple are not updated to reflect the receipt of funds. Theabsence of com plete and/or accurate records raises serious concerns as tothe accuracy and com pleteness of financial inform ation produced by thedistrict councils and therefore compromises their ability to be fullyaccountable.

.We are of the view that poor record keeping is exacerbated by inadequatesupervision by D istrict E xecutive D irectors and T reasurers w ho are oftennot awa re o f b acklogs.

Have weak internal colltrol system s. This includes the fact that cash bookbalances are not reconciled to bank balances and the failure to produceappropriate f inanc ia l s ta tements.. Have weak accounting capacity. Capacity for accounting and financialm anagem ent in district councils appears to be low considering that in the threecounc ils v isite d th ere were no qua lifie d a ccounta nts .

Are !lO t subject to any monitoring. In this context 1\1RALG and the otherministries do not undertake an active role in monitoring the performance ofcounc ils in te rms o f both fin an cia l p erfo rmance and te chnic al output... Are /lot subject to regular audits. Our survey findings indicate that capacityconstraints in the C ontroller and A uditor G eneral's (CAG ) office have resultedin audit backlogs21, T his combined w ith a failure on the part of district councils

to submit financial statements to the CAG have reduced the levels ofa ccounta bility a t a d is tric t c ounc il le ve l.

:1 H ow ever. w e understand that recently the C AG had m ade efforts to com plete the audit backlogs. In paru.:ular the m ost recent auditreport issued hy the CA G covers the audits of si"..y- tour local authorities for financial periods ranging betw een 31 D ecem ber J 993 and: \ 1 Decemhe r 1996 .

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~olume J . H ea lth Q na E dt/c allo l'! F ma nc la l T ra clc m.~ S tu dv . ~ ",m ar.. o fO bse rv aT JO ns. C on cillS /o ns a nd R ec omme nd aT io ns

74 It is n otewo rth y th at th e su rv ey fin din gs a re co nsiste nt w ith :. Audit findings from the fifteen programmes surveyed in health and education(m echanism 4). Sp ecifically, reco rd keeping at a district council w as reponed tobe inadequate for 8 programmes (53% of the survey sam ple). For exam ple, theaudit report on the National A ids Control Programme for the year ended 3 1December 1996 identified that no registers were maintained for recordingimprests and advances. Another example is the District Based Support toPrimary Education, which identifies the maintenance of stock records as aweakness.. A recent review of financial m anagem ent capacity in Phase I councils, whichonly rated three councils (8.6% of councils) as high in term s of their financialm anagem ent capability22. Interestingly all three w ere m unicipal councils.M oreover m ost rural councils (66% ) received a low rating. A "major area ofw eakness identified am ongst the low scoring councils w as the lack of up to datebank reconciliations". The report goes on to say that "in several cases these arecompleted only at the year end".

75 Some of the issues identified during the survey have been incorporated under theongoing Local Gove rnmen t F in an ce P ro je ct a s fo llows:. MRALG plans to provide district councils w ith technical backup. It isenvisioned that technical support w ill be organised into zonal and regionalteam s. Team s are expected to train and support finance personnel in the Phase 1councils.. A standard simple to implement accounting and finance system has beendesigned for use by Phase I councils. These proposals are currently underd iscu ssio n among th e v ario us sta keh old ers. It is an ticip ated th at o nce ag re emen tis reached, reports w ill be incorporated into a training pack and accountingprocedures for the Phase I councils. In addition, stakeholders will receivetraining on how to use the reports.

76 To enforce com pliance by councils we recommend that the CAG po.uibly with thesupport (~rlocal(v contrac ted profe. '; sionals undertake the fol lowing:. C lea r tlte a utlit b acklo gs.

Conduct a sun'ey of maintenance of internal controls by district councils.. Condu ct p erio dic su rp rise a nd in terim a ud its.

:: L ocal G ov ernm en t F in ance R efo rm P roject - R cv iew of L ocal A uth ority F in an cial M anag em en t C ap acity. P rice W aterh ou se -Decembe r 1998

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c \m y d oc lu nen "~ tea lU t an d e du ca uo n lin an e..1 u ack lllg s tu dy lf in al r cp on lfin al re po rt.d oc


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. - ., ... lees and m anagement of resources at primary- ~ L < " ) 1 ". ,Cu',:erView77 In this section we set out the key survey findings (highlighted in italics) andrec ommendatio ns (h ig hlig hted in bold a nd italics) on the so urces of reso urces availab le toprimary schools ,78 Major sources of resources for primary schools are government subventions andd onor contributio ns disbursed thro ugh the district co uncil, direct d ono r contrib ution s tos choo ls and par en ta l con tributions a t p rimary schools .Resources from central government and donors79 The survey of primary schools revealed that with few exceptions there are no cashdisbursements from central government or local councils or donors. The in-kindco ntribu tions from governm ent an d don ors take the form of:. Teachers.. Schoo l mate ria ls la rgely fin anced by donors .

Parental contributions.Teachers80 Teachers constitute one of the m ost significant contributions to prim ary education.The survey revealed that on average the Pupil to Teacher Ratio (PTR) for the districtssurveyed is eq uivalen t to the nation al average P TR of 1:37. :381 At the same time the su rvey results ind icate sig nificam disp arities in P TR b etw eenschools. In th e sam ple surveyed the scho ol w ith the:. Low est PTR of I: 10 had seventy-nine pupils enrolled, eight teachers and threec la ss rooms. This s choo l is lo ca ted in the wea lth ie st d is tr ic t.. Highest PTR of 1:145 em ployed one teacher. The school was opened in 1998,but had pup ils enrolled in stan dards one to six .82 The survey suggests that it is generally the case that the nearer the school 10 thedistrict headquarters the lower the PTR and this is a major factor (see Table 4.1). A

:3 B as ic S ta tis tic s in E du ca tio n - 1997. M inistrv of Education and Culture. June }998

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Volume I . H eallh a nd E dw callo n F ma ncla l Tra ckm g Stud y - S ummon " o fO bs er va llo ns " CO l'I Clu slo ns a nd R ec omme nd or lO ns

conseauence of this is that teachers in mOTe rem ote areas tend to have a heavier teachinsz-load"Table 4.1 - :\\'era1!e PT Rs cate!.!orised/b\' dista.nce from districts' headouaners

I...D istance from dist.ricts'. ..! h ead uan ers(K rns)/I Les s t h an 30O ver 30

2741

2642

2843

Source: V olum e II. Table D I.783 The disparity in PTR is more significant in terms of the location of the school fromthe distric: headquaners than it is betw een districts. This conclusion is panicularlysig nifica nt b eca use u ntil n ow th e issu e o f d ep lo ymen t an d efficien t u tilisatio n o f teac hersin Tanzania h as fo cu ssed on d istric t c omparisons24,84 W hile there is a large PTR disparity between districts there is a greater disparitybetw een schools" This m ay explain w hy there w ould be political pressure from districtsw ith relativ ely low PTRs fo r more teach ers. In fact th e su rv ey resu lts rev ea led th at d istrictsw ith h ig h PTR s were g en erally n ot the b en eficiaries o f n ew ly recru ite d teach ers in 1 99 7. Inpanicular, our survey suggests that some needy schools have benefited from thedeploym ent of new ly qualified teachers, especially in those cases w here teachers w erere spon sib le fo r mo re th an one c la ss .85 Another imponant conclusion from the survey results is that the inefficientd ep loymen t o f te ache rs th e most sig nific an t governmen t c on trib utio n to p rima ry educa tio nhas a high degree of w aste. In this context for example, the survey team cam e across caseswhere IlO sch oo lin g was ta kin g p la ce a t all (see Box 4"1). In addition, the survey team sawother cases where there are m ore teachers than classroom s resulting in loul reachinghours"Box 4.1 - 1m act of inefficient teacher de lovm ent

IiOne sc ho ol \'isite d is lo ca te d 5 6 km from th e d istric t h ea dq ua ne rs. T he sc ho ol h as a PTR o f I : 52 . se ve nI'

stream s. em ploys 4 teachers but only has 2 perm anent classroom s. T he schoors m anagem ent has built fourmake sh if t c la ss rooms u sing cOITUga te di ron she et ing. I n a dd it io n mu lt i- sh ir t- te ac hing me thod s a re p ra cti se d'I

fo r S tan dard s I an d II. H ow ev er. at any on e tim e at least tw o clas ses d o n ot h a\'e a teach er" F urth er. w hen anyo f th e te ac he rs a rc a bs en t from th e s ch oo l s tu de nts a re to ld n ot to b oth er a lle nd in g u ntil th eir re tu rn "86 On the other hand rhe survey team cam e across particularly commendable efforts byschool management in terms of initiatives and innovations in making the best of a badsiluation. For exam ple in one school located 138 km from the district headquaners therea re five teach ers a nd fiv e c lassro oms av aila ble fo r th e 2 44 pu pils en ro lled in e ig ht stream s,

~~ This issue of P TR s. efficiency and d~plo~m ent of teachers in district com parisons is discussed in several docum ents including PER sa nd E du ca tio n S ecto r d oc um en ts

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< 'J ny d oc ,u n. n" lh .a Jt h a nd .d ue au on f in an ci al tJ ae kU 1~ ,r ud )'\ fi na J r cp or t\ 6n a1 ,. pu n. do c


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, ,~ ;"d ,v . S umma ry o ;O bs erv arlO ns, C on clu sI on s a nd R ec ommen da lio ns

0-'" ---"'" lb''''''''.! ':

Q--w~;' i and IV.

D - c;ed on the issues identified during the survey we recommend that thel..

', ,~ . r,

.

In stitu 'te s mea su re s to ra tio na lis e te ache r d ep lo ymen t. In th is co ntex t it I:Y 1ayenecessary for the governm ent in addressing the issue of efficient use of teachersto ch an ge fo cu s from in ter-d istrict to in tra -d istrict an d in ter sch oo l comp ariso nsof PTRs. This should be facilitated by the decentralisation of teachers'emp loyment to lo ca l c ounc ils .Avail incentives/or teachers in schools located m ore than 30km s/rom thedistrict headquarters.

.

Sup ply o f sc hoo l materials88 T he survey indicates very low direct governm ent contributions to schools in term s ofraw materials, w hich w ould ordinarily be disbursed as other charges (see Section II, T able2.1). The average governm ent contribution per pupil is TShs 198. O n average the largestcon tr ibut ion is on examination expendi tu re .89 During the survey we noted that non-salary disbursem ents do not appear to be basedo n a ny ra tio na l fo rmula . E xpressed in term s of expenditure per pupil, the differencesb etw ee n d istricts are co nsid erab le (see T ab le 4 .2 ). T hese d iffere nces can no t b e ju stifie d o nequi ty grounds.

TShs MiDimum ' . Median19 9~629 627 1

35 15162 9

T ab le 4 .2 - Annual GoT con tr ib ut io n t o s choo l ma te ria ls ex513112 569 34 ~

S ourcc: V olu mc 1 1. Tables .4 .1.6. A 1.12 and D 1.190 T he survey confirm ed that donors supplem ent G oT in the supply of school m aterials.On av era ge d on or c on trib utio ns re ceiv ed from th e c en tre amoun ted to T Sh s 165 per pup il.91 The survey data also suggest that donor contributions to school m aterials are not inq ua ntifie s a deq ua te to meet sch oo l req uirem en ts. We undertook a physical count of theava ila bility o f S ta ndard V II te xtbooks in e ach s choo l. The su rve y co nfirm ed th at the re w ereschools in -which there were virtually no books for pupils in Standard VII. Table 4.3in dica tes th e mag nitu d~ of sh ortfa lls in term s o f sc ho ol materials at th e tim e o f th e su rv ey .92 .\nalysis of the survey results suggests a significant correlation betw een availabilityo f te xtb oo ks an d ex am in atio n p ass rate s. The schools w ith highest num ber of textbooks inS ta nd ard V II h ad th e h ig he st a vera ge p ass ra tes o ut of th e sc ho ols su rvey ed .

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Volume I. H ea ltn an d E ducQ lIon F ino m:/a / Tra ckm I1 Slu d\'. Su mm ary ofO bservollon s. C on clu sIO ns an d R eco mm ena ollo ns

Maths Kiswahili\

Science

! Avc ra c iI . 6 5 6 % 13S ou rce: V olu me 11 . Tab le D 1.2 193 In addition, on average direct contributions from donors, NGOs and charitableorganisations to schools in the sample surveyed amounted to TShs 6,984 in 1998.However, the survey also show ed a w ide disparity of m aterials betw een schools. In thisregard, as many as 56% of schools in our survey did not benefit from any direct donordisbursements.94 Considering the significance of school m aterials for the learning process, there isneedfor a:

. Substantial increase in government and donor contributions for schoolmaterials.l\t[ore transparent and r{ltional criteria by donors and governm ent for thed is tr ib utio n o f s choo l ma te ria ls .

P arental contributions

.95 P aren ts m ake tw o kinds of contributions to prim ary education for their children:. Con trib utio ns made to s choo ls .. Indirect contr ibut ions.96 By far the largest part (94% ) of parental contributions is earmarked for indirectcontributions. In m any of the sch ools surveyed paren ts m ake more direct contributions perpupil than d onors do. D irect parental contributions amount to about T Shs 1,900 per pupil.H owev er th ese co ntrib utio ns a re o nly a fra ctio n o f th e h ou seh old b ud get fo r ed uc atio n.C ontributions m ade to schools97 77 1ehu rden of parental con trihutions has increased sub stantially over the last tw oyears, although actual collections are considerably less than the fees levied (see T able44). O ur survey results suggest that this under collection could be attributed to a num berof fac tors :

. Parents had not finished m akin g paym ents on instalm en ts. III this respect 80% ofthe schoo ls surveyed accep ted ins ta lments .In-kind contributions were not reflected ill the reported figures for actual.collections. 24% o f th e sc ho ols su rvey ed a llowe d p aren ts to p ay fe es in -kin d.

.

. In poorer districts up to 58% o f par en ts c ou ld not a ffo rd fe es .(30)

c 'my documenL< lh e al th and educ a ti o n I in anc i ai lr ac kU l8 s i udy ll in a l r epon 'I in .1 ' epon .do e.


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V olu me I. H ea lrh a nd E du co C/o n Fmo 1'lC :io i T ra ck in fl S Tu dy -S ummar \' o fO bs er va tio n.f . C on cli l3 io ns a nd R ec omm en da tI on s

Indire ct p ar en ta l con tributions101 Despire the facr rhat household incomes are low ill rural areas, parenls appear tom ake lhe larg est con trib ution 10 edu ca tion. A survey of 450 parents revealed that theyspend on average additional am ounts tO talling TShs 3.1,16& per annum , w ith parents inp oorer d istricts spen din g up to T Shs 1 35,1 00 as o p.J)osedto a m ax im um o f T Shs 13 2,40 0 inrich er districts (see T able 4.6). A dditional co sts w ere m a.in ly used to pu rch ase tex tbo oks(3 2% ), ex erc ise b ooks (2 1% ) and unifo rm s (3 6% ).Tab le ~ .6 - Add itio na l

: TShs TSbs) ..31.168Source: \'olume II. Tables Dl.l1 and D 1.l3

Accounting and accountability for resources102 The survey also included a check on the schools management of funds. Neitherp are Ills n or d istric t o ffic ia ls co ve red in th e su rve y su gg este d w id esp re ad fra ud . However,during the survey it was revealed that a num ber of head teachers had been interdicted form isu se o f sch oo l fu nd s, in th e main p are nta l co ntrib utio ns.103 Surprisin g revelation s from the survey are th at:. As many as one third of schools do not maintaill bank accounts. In such casesth e cu sto dia n fo r th e fu nd s are th e H ead T ea ch ers o r V illag e E xe cu tiv e O ffice rs.

-/2% of lhe sch ools surveyed do not m ai1 llain rud im enta ry acco untin g reco rds.This practice is a cause for considerable concern w hen revenues collected andretained at the school level are increasing. This result is consistent with theoutcom e from m onitoring activities w ith respect to the Community EducationFund (C EF). The CEF, w hich disburses funds to a num ber of pilot schools notesthat parental contributions are less than pledges made. The m onitoring teama ttribute s th is under-r eporting to poo r re co rd keeping.

.

. A number o f sch ools d o no t m aintain in vento ry registers. In particu lar, w e foun dthat schools ill the survey were ullable to cOllfirm the receipt of 28% of thetex tb oo ks se nt to th em by th e d istrict co un cil.The level of accountability in schools is weak in a num ber of respects. A m ajorfinding in this respect is that reportin g of collectio ns and ex penditure in scho olswhich d eposit fu nd s w ith th e V illag e E xec utiv e D irec to r is almost n on -e xiste nt.Furthermore although the Local Authority Auditors should audit schoolaccounts , our sur vey findings sugge st that th is p rocedure is 110 tenfo rc ed .

.

(32)e :\m y d oe um cn ls lh calth an d e We alio n o na ncia l tn ck mR $ lU dy lf ma l r ep or tllin al re po rt.d oc


35/48

'-.-"

p,.~ ,.. . . ..~;:dv - S ummar y o fO bs er va llo ns . C on clu si on .r a nd R ec omm en ck ll 1o ns

v findings indicate that poor financial m anagem ent is a weakness in the"'Tding school funds. In this context thereforewe recommencl that:

'!:c' ". 'c"jui.rcd to o pen b an k ac co un ts.

.

", ~

". - ". . , ". .' ...

y r,.. r ..,. -.,.,'r ~ . c,''''. ~~ ."..~;. . ' .. . .l:.'..'" . "; '' ''. .., : . -' ''' ' ' ' ' ' ' '- ''..:.'"'6~-. '~._ , ~~

...' ', ". '; ,.. .'" ~.':.. !.-.~, 4 ' ",' . ~ _t'_- ~''-'''''j ! r,-..~ '(Jut inform ation on how to manage, account for and report on school funds.

The handbook should at the m inim um set out procedures for: using four bookso f acco un t, th e ca sh b oo k, fe e reg iste r, ex pen ditu re re gister an d in ve nto ry le dg er(stan dard ised fo rmats sh ou ld b e in clu de d fo r co nsisten cy ); ex tractin g d ata frombooks of account for reporting purposes. T he financial m anagem ent handbookcould initially be used to train head teachers as part of the school m anagem entc omponen t p la nn ed under th e Educa tio n Sec to r Development P rogramme .Schools Inspectors or Auditors from the CAG on an annual basis, to test andc on firm th e a ccu ra cy of f in an cia l reco rd s main ta in ed a t sch oo ls.

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W age biD To ta l r esour ce sTotal i n-kind received from

the cent re55% 45% 100%710 29% 100%64% 36% 100%

Volume 1- H ealth and E duco/lon F inonc/ol Trackm g Study -S ummo '" o fO bs er vo 1/o ns . C on e/u s/o ns a nd R ec omme nd otio ns

V Sources andfacilities mana2ement of resources...... at health

Introduction105 In this section we set out the key survey findings (highlighted in italics) an drecommen datio ns (h ig hlig hted in b old and italics) on the so urces of reso urces av ailab le toh ea lth fa cilitie s, a nd how we ll h ea lth fa cilitie s u se a nd a cc ount fo r s uc h re so urc es.106 M ajor sources of resources for health facilities are governm ent subventions andd on or con trib utio ns d isb ursed thro ugh th e d istrict co unc il, direct d on or co ntrib utio ns tohea lth f ac ili tie s and u se r cha rges .Resources from governm ent and donors107 The balance of contributions from the centre (governm ent and donors) generallytak es the fo rm o f in -k in d con trib utio ns (see T ab le 5 .1 ). T hese are:. The wage b ill.

In -k ind con tr ibutions o f medi ca l s uppl ie s and equ ipmen t..ln~kindcontributions

DnJgs Vaccines Materials Equipment

! In s i ta lsI k ah h C ~n trcs ID is ~ ns ar i~ s I

34% 12% 6% 4%13% 35% 30 0%55% ~O '. /0 40 . 10'0

Source: V olum e II, Table C 1.7 and C 1.9\Vage bill108 The surv ey show .\' th at hospita ls r ec eiv e -/5% of their contributions by w~v of w agehill paym eJ1lS met by the governm ent. The ratio of wage bill to other resources at PHCfacilitie s is sig nific an tly lowe r a t about 30% .109 H ealth w orkers constitute the highest G oT contribution to prim ary health care. Thesurv ey reve aled th at on average the highest proportions of health sector employees ind istr ic ts a re d ep lo yed a t d istric t h osp ita ls . D istric t h osp ita l bas ed work ers c on sume a round60% o f th e p er sonnel e xp enditu re d is bu rsements r ec eiv ed from cen tra l gov er nmen t.110 In addition the survey also revealed that d istrict h ospita ls tend to h av e the majority o fskilled sta ff (p articu la rly reg istered n urses a nd ~ ssista nt nu rseJ~ (see Table 5.2) As aresult staff deployed at health centres and dispensaries tend to be less skilled. Thissk ewedne ss in s ta ffin g is p erc eiv ed to a dv erse ly a ffe ct th e e ffic ie nt a nd e ffe ctiv e u tilisa tio n

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< .'m y d oc wn cn lsl hc :o ltl l a nd c du ca bo n 6 na nc i: ol u ac ki ng l ru dy \6 n:o l r cp on lt in al r cp on .d oc


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Volume / . H ealth an d E th lcclltm F lf/a ncla! T rackm g S tud y. S um ma ,...' o f O bserva tio ns. C on clu sIo ns o nd R ecom men,hm on s

finances m ost in-kind contributions received by district hospitals. In 1998,m ed ical supplies distribm ed to bospita1s (included in tbe M inistry of H ealth'sbudget a llocat ion -Mechanism 3) on averaae am ounted to 300.10 f the averaae- -to ta l re sourc es re ce iv ed by th e d is tric t h osp ita ls s urv ey ed .. A standard issue of blue and yellow kit ,is d istributed every month to each healthce ntre an d d isp en sary re sp ectiv ely . T he su rv ey re vealed th at g ov ernmen t (5 3% )and donors (47% ) jointly financed kits disbursed in 1998. In addition, healthc en tres an d d isp en sarie s rec eiv ed v ac cin e su pp lie s fin an ced b y g ov ernment a ndd on ors su pp ortin g th e p ro grammes u nd er mech an ism 4 .

114 T he survey covered a num ber of aspects under each system as follow s:. Whether in -k ind con tr ibuti ons r each hea lt h f ac ili tie s.. The ex ten t to which reso urce req uirements a re met..-\vailability on the day of the survey w ith respect to a basket of commonly useddrugs..

E fficiency of system s for d istrib utin g m edical supp lies115 The survey team found that medical supplies zm der b oth allocation system s reachhealth facilities. Our su rv ey fin din gs are co nsisten t w ith a much more ex te nsiv e su rv ey th atw e undertook for GoT and DANIDA. The survey covered drug and vaccine distributionfrom 1 July 1996 to 31 December 1997. W ith respect to the distribution of drug kits,consultants reported an immaterial difference of 0 .3% betw een d rugs d espatched from theMedic al S to re s Department a nd volumes re ce iv ed a t d is tric ts.Extent to w hich resource requirem ents are m et116 R esponses received from the m anagem ent of the various health facilities surveyedin dica te th at (see T ab le 5 .4 ):

.H ospitals are m ore likely than health centres and dispensaries to have theirr equirements fo r med ic al supp lie s met.D ispensaries tend to be better supplied with medical supplies thall healthc en tr es. a lth ough th er e a re signific allt d is tr ic t v aria tio ns. Also, th e a llo ca tio nsd o n ot ap pea r to b e clo se ly rela ted to th e cu rre nt u sag e o f h ea lth fac ilities.

.

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c "m y d ocu me nts lh ealth a nd e du ca tio n fin an cia l tr ack in g s lU dy llin al r ep Mlfin al r ep or t.d oc


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..... .................. . Go\ 'emment .. .............................. ........i. .....-.---.-- ...........i


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'.".'.

" .,'(

. _ .~ .. -~--. .- .~ '4*> ' '~ '- . .. ~. .. ~ ._ ,. ,. .

..est co llectio ns w ere from d ru gs a nd va ccin es (43%), reg is trat ion (20%)"' ; ,1 fa tio f1 fees (J 8%).

...-: T t\C 2Je d th at non-governm em health facilities are charging. '. . ~ ',! ~ ,:r-g~'s. For instance one NGO run dispensary which treats 500outpatients a m onth collects substantially m ore revenue (280% m ore in 1998) than thedistrict hospital. Part of the difference is attributable to the fact the NGO dispensary has a100% recovery rate on drugs. In this regard therefore, we consider that there is a need

for a study on optim al policies and strategies to guide the levying of user charges.U tilisation of user charges126 Governm ent dispensaries that charge user fees in our sample do not retain them .Instead dispensaries are required to rem it collections to the District M edical O fficer(DMO ). D uring the survey the DMO confirm ed to us that he deposited such collections ina special account called the "Health Services Fund Account". Further, our team alsodiscovered that funds from this account are used to purchase medical supplies for thedistrict hospital and not for dispensaries. This may act as a disincentive in terms ofm axim ising collection at dispensaries. It is recommended that dispensaries stopsubsidising seT Yices at district hospitals. In addition, to provide incentives and ensuremaxim um collection of user charges at dispensaries, it is essential they are allowed toretain all or m ost of the user charges levied127 Our survey revealed that on average district hospitals spend a considerableproportion of revenllesjrom user charges collected on drug purchases (36.4%) andequipment purchases (3 6% ) (refer to T ab le 5 .6 ).

i Tot alS ou rce: V olum e 11 . Tab le C 1 .13

D rug and vaccine utilisation128 T he survey collected data on drug and vaccine utilisation. In determ ining the data toCQ!j.:.::~nd m easures T o be used, w e applied the follow ing World H ealth O rganisationoutcom e indicators (OTs) and other indicators to evaluate the efficiency of drug use athealth facilities:-

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-V olum e I -H ealth a nd E du co tlon F inan cial T rQ clc m~ S lu dv . Sum mary ofb5 erv atio ns. C onc lu sion s on d R ec om me nd atIO ns

.A '\'erage stock G ut - w e estim ated the num ber of w eeks taken to deplete bluea nd y ellow k its .O T6 - ExpiFed drugs w hich m easures the "num ber of drugs beyond the expiryd ate, o ut of th e to tal n umber o f d ru gs su J"lley ed".

-, ..,.~

.OT7 - R ational U se of D rugs, w hich m easures. the "average num ber of drugs. . "er prescnptJon .O T8 - Injection U se, w hich m easures and the "num ber of prescription w ith atle ast o ne in je ctio n, o ut o f th e to ta l n umber o f p re sc rip tio ns su rv ey ed .

.

V accine use - w e com pared actual num bers of patients vaccinated againststa nd ard n umbers th at s ho uld h av e b ee n v ac cin ate d.

129 Our survey results are as follow s.

.130 A verage stock out-W ith respect to the utilisation of resources, w e noted that mostfacilities tend to run out of drugs w ithin three w eeks (refer to T ab le 5.7 ). A ll h ealth cen tresand dispensaries are allocated a single drug kit every m onth regardless of the volum e ofp atients seen . Our co nclu sio n th erefore is th at th e d rug alloc atio n sy stem d oes n ot resp on df lexib ly t o th e needs o f indiv idua l f ac ilit ie s.Table 5.7 - A vera2e len2th of time taken to de lete commonlv used dru contained in kitsTvpe o f f ac il itv I"," " 'A ,'eraeIcn!!thoftimctakcntode letekits .,'.. Four weeks Three weeks I U to two weeksDisDensaries 12.50% 70.83% 16.67%Hcalth centres 50.00% 16.67% I 33.34%Sourc~: V olum e II. Table C 1.18131 W e also observed that th e in troductio n o f u se r cha rg es in gov ernment PHC facilitie sappears to reduce the dem and for drugs, thereby decreasing the likelihood of stock O llts.We therefore conclude that user charging m ay assist the governm ent in prom oting m orerational drug use. H ow ever, "research indicates that to concentrate exclusively on drugsupply and cost recovery is a lim ited approach that fails to m axim ise the usage of healthfacilities by vulnerable groups" 27 . W e therefore recommend that the governmentllntJertake an assessm ent of health care needs taking into account community attitudesand re.'iOUrceavailability, the outcome of which should be a rational basis on which(Jrugs are al/ocated.132 OT6 - Expired drugs. Our survey results indicate that the levels of expired drugsparticularly at health facilities are immaterial. In particular, the m ajority of healthfa cilitie s su rv ey ed d id n ot h av e a ny e xp ire d d ru gs .

"H ow to investigate dru g use in h ealth facilities - Essential D rugs M onitor ~o 14 of 1993(40)

e :\ m) ' Q oc um c nb lh ca J1 I1 a nd c du e. bo n f in an ci al u .c ki ng s tu dy lf in aJ I ep OI tI fi n. l r ep on .c Io c:


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"

. :. ~:I./(Jy . S umma ry o (O bs er va llo ns . C on clu sIO ns a nd R ec omme nd atio ns

'- .,.'"\ ~ 0-.' '.'""- ..,... 4' . ~ '. ""~~"" ''''' " '~ ''''''''OL - '"' t-. '~';;"-~"r

...~ ;

:,llshed the average number of drugs prescribed per encounter as 1 .6 3. On ave ra gec tend to prescribe few er drugs per patient encounter than priI!1ary health care. '':'\'e;.\-e''es~t~ e o ve ra ]] a ve ra ge num ber of drugs prescribed per encounter is. - ~

134 OT8 - Injectio n U se. Our surv ey resu lt shows that:Z,1 ':. A'"Gove rnmen t h osp ita ls. h ea lth c en tre s a nd d isp en sa rie s a dm in iste re d an in je ctio nin e ve ry 5 Ou!of60 (8% ), 15 out of 100 (15%), and 81 out of 360 (23%) patientvisits respectively.

. Non-governm ent dispensaries adm inistered an injection in every 20 out of 140(14.2%) pa tien t v is it s.

135 This result suggests that injections are overused at governm ent dispensaries28. O nthis subject the MoH recommends that injection use should be lim ited to 15% or less for alltype s o f hea lth f ac il itie s.136 Injection use is discouraged for a number of reasons. Public health specialistsperceive that "from an econom ic view point, the irrational use of injections im poses anadditional burden on lim ited household and health centre budgets, particularly in A fricaw ith its co ntin uing eco nomic crises"29 . F urth er, research p oin ts to the fact th at in creasedin je ctio n u se in cre as es th e ris k o f p atie nts c on tra ctin g lo ca l in fe ctio ns a nd th e tra nsm iss io nof H IV and H epatitis B virus" 30 .137 To m inim ise injection use, the M oH should in future consider reducing the supplyof injections to PHCs. In addition, we recomm end that district based medical staff:should educate patients on the draw backs of injections; use patient records to m onitorth e levels of in jectio n use.138 Vaccine use - Our survey data indicates that there is a considerable wastage invaccin e u se (see T able 5 .8). T his wastage is particularly h igh in h ospitals an d d ispen sariesw here w astage ofBCG is 76% and 67% respectively.139 These results imply that for each vial of BCG, DPT, Tetanus, M easles and Poliovaccine provided to health facilities an average am ount of TShs 577, TShs 68, TShs 295,TShs 333 and TShs 585 is lost. In terms of vaccines distributed to the three districtssurveyed this represents 5% of total resources distributed to health facilities from thecentre.

.

:8 This result is sim ilar to research findings w ith respect to government PH C facilities in D ar es Salaam , w hich estim ated injection use as28.7%, '9 Investigating po pular dem and for injection s in Ind onesia and U ganda - E ss en ti al D ru gs Mo ni to r N o 2 3 o f 1 99 730 ihid.

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r'olu me I . H ea lth a nd E du catIo n F "tor/cial Tra cking Stu d}'. S um mary o {O bserva llo ns. C onciu Slo ns an d R eco mm en da tio ns

140 We shared these survey fi~dings with officials in MoH managing the ExpandedProaramme on lmmun:sation w ho are of the view that th ese results in dicate hig her w asta!!e- .. --han w ould norm ally be expected. A ccording to tbe M oH in general vaccine w astage ratesshould be between 200,10and 30% . The only exception to this is the BCG wastage rate,w hich they w ould expect to be around 50% .141 Further, the M oH were of the view that the high wastage rates reported during thesurvey could result from one or m ore of the follow ing :. Inaccurat e record-keep ing a t hea lth fac il it ie s.

Shortages of kerosene needed to run cold chain equipm ent. This is consistentwith findings reported by the Expanded Programme on Immunisation(mechanism 4) which noted delays in disbursing funds for the purchase ofkerosene. This resulted in vaccines being destroyed or tem porary cessation ofimmunisation activities at PHCs as vaccines had to be sent back to the districthospital for ref rigera tion.

.

. Oversupply from the centre. This is particularly the case for the polio vaccine.W e understand that perhaps under the recent National Immunisation Daysin itiativ e (Mechanism 4 ) more v acc in es w ere d istrib uted to h ea lth fac ilitie s th anwas actually needed.Unu sed v ials whe re a tten dan ce is p oo r. H owev er, h ealth fa cilities (p articu la rlyh osp itals) are en courag ed to send open ed te ta nu s v ials to o ut p atie nt d ep artm en tsas th ey can be used to treat acciden t victim s.

.

: D i spensar ie s

T ,' c of vaccine..j TetanusIIIMeasles

40%20%~8%

Polio76%45%67%

31%25%18%

63% 68'Yo47%9%

50% 62%S ou rc.:: V olu m.: 1 1. T ab l.: C 1.2 0142 To im prove th e utilisatio n of vaccines we recommend thefollow ing:. Rational criteria ..;/wuld be developed by donors and government for the

a llo ca tion o f vaccines to hea lth fa cilitie s.A lter 1'llccine ses.fiio n.fito days w hen health facilities expect to cover a larg epopulation... E ,zsure regu la r su pply of kero sene to P RC s.S tre ng th en superv isio n b y D istrict C old Cha in O ffic ers.

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,.

'"' . .,,- -- 'm . .~ ' .I.:'; - ; ,..m ma ry o /O bse rv allo ns . C on clu sio ns a nd R eco mm en da tio ns

.~

~nd accountability fo r funds~- - - ( '-~ ".~ .-" ",,,,,,,~ ~+ n 0~ ~;~ :; '~ : '~ '~ ,.e ',~ ~d .\.~ .. ,. ~:r,"':~"'~_. -V-'",,;\.1 r sim ply not recorded. W ith respect to:

r Itt wa.\ c.. ~ - 0::' % of the health facilities surveyed that colJect user chargesgrant exem ptions to an estim ated 34% of the p atien ts trea ted .

...

. In comple te re venue amounts - b ased o n material d ifferen ces b etw een n umbersof outpatients treated at an NGO dispensary surveyed and district hospitals w econ sid er th at it is lik ely th at th ere a re in effic ie nc ie s in colle ctio n p ro ce ss es .

144 We also found that district hospitals have in place com rols to ensure that fundscollected from user charges are safeguarded. In p articu la r, h osp itals ha ve th ree acco un tsign ato ries, th e D istrict Med ica l O fficer, h osp ital ac co un tan t an d a member o f th e D istric tHealth Iv1anagement Team.145 In addition, we tuund that district hospitals regularly report on revenue from usercharges and related expenditure using the H ealth M anagem ent Inform ation System(MTUHA ). T his finding is consistent w ith data contained in the M oH 's 1998 statisticala bs tra ct, wh ic h re po rts h igh d is tric t re spon se ra te s to re po rtin g re qu iremen ts .146 H ow ever, the survey revealed that the fO llr pilot dispensaries charging user fees donot m aintain bank accounts. F urtherm ore, collections are not deposited in safes. In thisregard, w e recommend that all dispensaries charging user fees are required to open banka cco ullts a nd p rep are reg ula r statem en ts o f a cco un t.147 Our survey also suggests that although hospitals should be audited sem i-annually bythe respective R egional Internal A uditor and CAG , that there are backlogs in reportingaudit findings. In add itio n, our re su lts in dic ate th at no aud its a re underta ken a t go~ 'e rnmentPHCs,I 48 To improve accountability over the collection and use of resources at healthfacilities we recommend that the CAG :

.Clears any bac klogs .Conducts periodic surprise spot checks at all PHCs to confirm thecomple te ne ss am i a ccurac y o f c olle ctio ns .

.

. U'idens his audit scope to evaluate value for money in the use of drugs andva ccin es a t PHCs.

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. -.. _.. --.,' ."T"""_.'--.'."" -"..~-'.""'-

:1 - Dire ct donor con trib utio ns appea r to fa vour d is tric ts, whic h a re e conomic allymO lt.: \->Jeiioff. in view of donors' commitment to combating poverty theyshould collaborate between themselves and GoT to ensure that the moreeconomically worse off districts are priority beneficiaries of their::(>Y..l.~'"~,"> I.,.

. 7 - Som e councils do not use any of their ow n resources to funa education andhea lth a ctiv itie s where as o th ers make s ignific an t c on trib utio ns. In the spirit ofsupporting sustainable social and econom ic developm ent, councils should beencouraged to earm ark a proportion of their ow n revenue sources to supportprogrammes in health and education.8 - There is a dea rth o f ca pacity a t a district le vel p articula rly in th e area s offin an cial m an ag emen t an d au dit. S ome o f th e issu es id en tified d urin g th e su rv eyhave been incorporated under the ongoing L ocal G overnm ent F inance Project.T o support the process w e recommend that the C ontroller and A uditor G eneralwith the support of locally contracted professionals conduct a survey ofmain te nanc e o f in te rnal c on tr ols b y d is tric t c ounc ils .

.

Schoo l le ve l. 9 - There is inefficiency in the deploym ent and utilisation of teachers. This isdemonstrated by significantly w ide disparities in PTR betw een schools and tole sser ext en t d is tr ic ts . We recommend that the governm ent institutes m easuresto ra tio na lise tea che r d ep lo ymen t g ivin g pa rtic ula r emphasis to intra -d istrictand inter-school comparisons. In addition, we recommend that thegovernm ent avail incentives for teachers in schools located m ore than 30 km sfrom th e d istr ic t h eadqua rte rs .10 - R esources allocated by governm ent and donors for sc

Pets Study-pwc 1999

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