Resource Tracking for Financial Accountability

1. Resource Tracking for Financial Accountability Nirmala Ravishankar Washington, DC January 25, 2010

2. Outline • Brief Introduction to National Health Accounts • NHA as one of many Resource Tracking Tools • Harmonizing Resource Tracking Tools to Improve Planning and Financial Accountability • Ongoing Harmonization Efforts in Rwanda

3. NHA: An Introduction

4. National Health Accounts (NHA) Method for measuring total expenditure on health in a country including public, private, and donor contributions Builds on OECD’s system of health accounts Internationally accepted and tested (100+ countries) Application to priority areas has led to development of NHA subaccounts HIV/AIDS subaccounts RH subaccount Malaria subaccount CH subaccount

5. NHA tracks both the AMOUNT and FLOW of funds through the health system MANAGERS of funds: Have power and control over how funds are used i.e., programmatic responsibilities: e.g. MOH, insurance companies Financing Source $ Financing Agent End USERS of health funds: Entities that provide/ deliver health service . e.g., hospitals, clinics, health stations, pharmacies Originators of health funds: e.g., MOF, households, donors Actual USE of funds: Service and/or product delivered. e.g. preventive programs, curative care, admin Health Provider $ Function $ $

6. NHA makes sense of a complex system of flows…

7. To do that, it uses a variety of sources • Executed budget of the government • Institutional surveys • Donors and UN agencies • NGOs and other implementing partners • Employers • Insurance providers • Household survey of health expenditure • Secondary data sources • HMIS • Facility data on utilization • Others

8. Total health expenditure as percent of GDP in Namibia grew in first half of the decade

9. International assistance accounts for biggest share of health resources in Rwanda 53% 1% 28% 42% 50% 33% 25% 52% 42% 19% 40% 30% 32% 25% 10% 18%

10. NGOs and international agencies emerge as biggest managers of health spending in Zambia Total: $133,918,260 Total: $164,810,839

11. Reflecting on NHA in Africa: The need for institutionalization But NHA estimations continue to be costly, time-consuming, and require considerable external technical assistance. At least 25 countries are completing or have done an NHA. Some – like Rwanda – have done multiple rounds. Egypt Mali Niger Burkina Faso Nigeria Ethiopia Liberia Uganda DRC Cote d’Ivoire Kenya Ghana Rwanda Togo Tanzania Benin Malawi Zambia Mozambique Zimbabwe Mauritius Namibia Use of NHA needs to be enhanced. Madagascar Botswana South Africa

12. Addressing barriers to NHA institutionalization

13. Demand for harmonized resource tracking Harmonized resources tracking is a key part of the institutionalization agenda.

14. Viewing NHA in Larger Context of Health Resource Tracking

15. What is resource tracking for health?* • Health resource tracking tools measure and analyze the flow of financial resources for improving health • They track how much is flowing, from whom, through whom, to whom, and for what purpose *Sources: Powell-Jackson & Mills, A Review of Health Resource Tracking (2007); Berman, National health accounts in developing countries (1997), Schieber and Poullier, International health care spending (1986); Levine and Blumer, Gaps and Links: What do we know about resource flows in global health (2004); Ravishankar et al., Financing Global Health (2009).

16. Two levels of resource tracking • International development assistance for health • Resources for the health sector within a country

17. International resource tracking tools • Track international resources for improving health in developing countries • Typically focus on commitments, disbursements, and in-kind services (medical commodities, TA) • Examples: • OECD-DAC’s databases • IHME’s development assistance for health database • PLAID database

18. National resource tracking tools Some are focused on the health sector while others are not • Track the flow of funds within a single country • Many RT tools at the country-level have been standardized internationally • National Health Accounts (NHA) • NHA subaccounts (HIV/AIDS, RH,etc.) • National Aids Spending Accounts (NASA) • Development Assistance Database (DAD) • Public Expenditure Tracking Surveys (PETS) • Countries have developed additional tools reflecting their needs • E.g., Joint Annual Work Plan (Rwanda) Some are disease-specific Some assess past expenditures while others focus on budgets

19. Distinguishing between different kinds of “tools” in use in developing countries Multi-Sector Assessment e.g., PER Multi-Sector Planning e.g., MTEF Health Sector Planning e.g., Health sector plans, national AIDS strategies Health Sector Assessment e.g., Health PER Costing e.g., MBB, HIV/AIDS costing tools Resource Tracking e.g., NHA, NASA, PETS, DAD

20. Purpose of resource tracking To generate evidence that can: • Enhance coordination among donors at the international level • Feed into the planning cycle and improve resource allocation at the national level • Be used to mobilize more resources for neglected areas and the health sector as a whole, both internationally and nationally • Be combined with measures of health system output and outcomes to assess the performance of health systems • Improve financial accountability by tracking flow of resources from financial source to the service it was used to deliver

21. Harmonizing Resource Tracking Tools to Improve Policy Planning and Financial Accountability

22. What does harmonization of resource tracking mean? (1) Rationalizing data collection systems so as to reduce the burden of data reporting and increase efficiency • NHA HIV/AIDS subaccount and NASA have considerable overlap. Combining data collection efforts reduces burden of reporting and saves both time and money (Rwanda, Namibia, Ethiopia, DRC) • Including health expenditure questions in ongoing household surveys like the DHS, MICS, PLWHA surveys, etc. saves need for stand-alone surveys (Rwanda, Namibia, DRC) • Tracking facility-level expenditures as part of a country’s district-level HIS can generate much-needed information cheaply and on a routine basis (Rwanda, Liberia)

23. What does harmonization of resource tracking mean? (2) Greater coordination between donors and government agencies • Donors work with different government agencies in the same country. They each have different timelines and deadlines, which need to be synchronized (Rwanda) • To be relevant, RT information needs to be produced at the right time in the Government’s planning cycle (Kenya and Rwanda)

24. What does harmonization of resource tracking mean? (3) Build linkages between RT systems to increase financial accountability • OECD-DAC tracks commitments and disbursements to the implementing partner in a country. NHA and PETS track what happens to the money once it enters the country and how it is spent. Combining these two will lead to complete financial accountability. • In Rwanda, JAWP tracks planned expenditures while NHA tracks actual expenditures. Ideally, you would like to be able to compare planned with actual expenditures by different actors.

25. Rwanda’s Resource Tracking Harmonization Initiative

26. Rwanda is a pioneer in the resource tracking realm • Rwanda has implemented multiple rounds of internationally recognized resource tracking and resource allocation analysis tools including • National Health Account (NHA) and subaccounts for HIV/AIDS, malaria and RH • National AIDS Spending Assessment (NASA) • Development Assistance Database (DAD) • It has developed resource tracking systems of its own to suit the purposes of GoR and its development partners • Joint Annual Work Plan (JAWP)

27. Despite these achievements, significant challenges persist • While each of the activities serves a valuable function in its own right, they collectively place a heavy burden on all stakeholders • Harmonization of different resource tracking activities is needed to: • Reduce the burden of data reporting • Build analytical linkages between the different resource tracking exercises • Domestic capacity for undertaking resource tracking is low

28. Ongoing harmonization efforts in Rwanda • Undertake a systematic review of all RT activities in the health sector • Design and implement a harmonization strategy over the next six months to create ONE resource tracking system which • Rationalizes institutional data collection • Synchronizes RT with the government’s planning cycle • Implement harmonized resource tracking with Rwanda School of Public Health, specifically: • Train them to undertake RT exercises upon request from MOH • Develop RT curriculum as part of regular curriculum which they can use to train others • Include household expenditures questions in the upcoming DHS

29. Harmonizing data collection platforms: Reviewing inputs We need the Ministry’s detailed planned and executed budgets. • NHA Inputs • MOH executed budget • Donor and NGO surveys • Employer survey • Insurance survey • Household expenditure survey • NASA Inputs • MOH executed budget • Donor and NGO surveys • Provider survey • JAWP Inputs • Donor and NGO surveys • MOH planned budget If we don’t coordinate data collection, we will be approaching partners 3 times!

30. Harmonizing timing of data collection: Pending questions When is MOH’s budget for upcoming FY finalized ? July 2009 Government of Rwanda June 2010 When is MOH’s executed budget for past FY finalized? Is it correct to assume that on-budget support will follow same planning and execution cycle? When can implementing partners report their planned expenditures for the next FY? Oct 2009 Sept 2010 USG and all its implementing partners When can implementing partners report expenditures for past GoR FY?

31. Conclusion • NHA has made great strides in Africa and around the world • The larger NHA stakeholder community is rightly focused now on NHA institutionalization • Harmonizing NHA with other resource tracking activities and the planning cycle of developing countries is a key part of the harmonization agenda • It will serve the dual purpose of: • Making NHA production more efficient and reduce burden of data collection • Generate greater demand for and policy use of NHA data

32. Further Readings Using NHA data for policy use and policy reform • NHA accelerates pro-poor reforms in the health sector in Kenya http://healthsystems2020.org/content/impact/detail/2290/ • From Emergency Relief to Sustained Response: Examining the Role of the Private Sector in Financing HIV/AIDS Services http://www.psp-one.com/files/5355_file_From_Emergency_Relief_Final_Report.pdf On harmonization of resource tracking tools: • Linking NASA and NHA: Concepts and Mechanicshttp://healthsystems2020.org/content/resource/detail/2321/ • National Health Accounts and Public Expenditure Reviews: Redundant or Complementary Tools?http://healthsystems2020.org/content/resource/detail/2240/

33. Thank you Reports related to this presentation available at www.healthsystems2020.org