Transparency and Accountability Program Independent Monitoring Organization Studies (2007 – 2008)

1. Transparency and Accountability ProgramIndependent Monitoring Organization Studies (2007 – 2008)

2. Albania Center for Economic Research (ACER) • Expenditure tracking of health facilities • Primary Health centers, Hospitals • Survey of institution heads, local officials, patients • Results • Despite recent decentralization efforts, researchers found evidence that health funding decisions are made by a handful of Ministry experts and politicians • Rather than working to bolster public trust in primary care facilities, the central government allocates 50% of the health budget to hospitals, leaving primary facilities severely underfunded • Although the government ensures health insurance for all citizens, ACER survey provides evidence that less than half of the population is insured

3. Bandung Institute for Governance Studies (BIGS) - Indonesia • To discover how well local governments are doing in health and education service delivery, BIGS examined budgets for 3 cities in West Java • Desk study (unpublished data), Interviews (Local and Central Level), and FGDs • Results • Lack of clarity about budgeting responsibilities among levels of government • By simply examining 2004 - 2007 budget data, BIGS found that local officials (like national officials) are not reaching the spending targets for health and education

4. Centro de Análisis y Difusión de la Economia Paraguaya (CADEP) - Paraguay • Expenditure tracking in primary schools around Asuncion • Surveys of school directors, teachers, parents, and Ministry of Education officials • Reviewed budget data and primary site analysis • Results • Found that budgeting is too opaque to be monitored by civil society • Principals, though responsible for budgeting, lack skills/training to manage budget (20 out of 23 principals unable to budget) • Parent associations frequently pay for maintenance and services such as electricity and water • Programs fail due to lack of knowledge by MoE (ex - Academic Kit program) • Researchers utilized the high interest and engagement of parent associations to develop posters for schools outlining how parents and students can start to monitor education services and to whom problems should be reported

5. Centre for Budget and Policy Studies (CBPS) - India • Evaluated health and education budget data for two districts in Karnataka • Udupi – richer, more progressive • Chitradurga – more rural, worse development indicators • Results • Found that spending decisions do not reflect local needs – requests of districts (ZPs) are not reflected in allocations from State • Incomplete and ineffective record-keeping on ZP spending (for example, no record of salary versus non-salary expenses) • Funding does not reflect deomgraphic changes – drastic increase in patients in Chitradurga (2003-5) met with 11% cut in health spending • Recommend greater communication between ZP and State in determining budget allocations • Impact • Analysis, findings, and video are being used by advocacy NGOs that could not do this work themselves, one of the goals of CBPS. • Video showed some government officials explaining away the problems and other successfully acting to solve them.

6. Finding Center for Democratic Development (CDD) - Ghana • Teacher absenteeism study in Ghana primary schools • Surveys (teachers, head teachers) and unannounced visits to schools in 3 districts • Results • Found 47% of teachers were absent at least once during 5 school visits • Absence rates higher among professional teachers (57 vs. 36%), males (50 vs. 41%) • School characteristics such as staff room, access to potable water, and close proximity to health clinic associated with lower teacher absence Absenteeism peaks on Fridays (40% of teachers) Salaries should be paid to teachers, near schools, or on Saturdays Education officials should actively encourage formation of PTAs in schools Weekend long-distance education lectures should be moved (time or location) Recommendation Evidence that teachers miss class to collect salaries Absenteeism and active PTA negatively correlated

7. Finding Recommendation National Center for Economic Research (CIEN) - Guatemala • Expenditure tracking of 6 primary school programs in Guatemala City • Scholarships, Meals, Milk, Textbooks, Supplies, Teaching Kits • Surveyed students, teachers, and parents • Results • Funding inadequate – Meals and Milk programs especially underfunded (27% and 28% reported sufficient funds for all students respectively) • Major delays in funds/supplies arriving in schools 28% of primary school students had books and only 7% had school supplies in the first school month of 2008 Schools should start after the fiscal year to give time for money to flow, improving chance that resources get to schools on time Ministry of Education announced that school start would move from January to February in 2009 Impact

8. Center for Implementation of Public Policies Promoting Equity & Growth (CIPPEC) - Argentina • Estimated incidence and cost of high school teacher absenteeism and school closures in 2 districts in province of Buenos Aires • Florencio Varela – 27% households with unmet needs • San Martin – 11% households with unmet needs • Results • Found 40% higher Absenteeism in Florencio Varela • Reported causes of absenteeism – personal illness (40%), family illness (14%), unknown reasons (18%) • Few principals try to curb absenteeism – those who do use distribution of statistics about how disruptive absenteeism is, dock pay, or mark teachers down on annual evaluations (resulting in union pressure) • Recommend improving conditions for teachers and methods of record-keeping

9. Research Center of the University of the Pacific (CIUP) – Peru (1 of 2) • Analysis of implications of Results-Based Budgeting reform in Peruvian health and education sectors • Pilot – primary education, maternal and neonatal care • National budget data and limited interviews (beneficiaries, program officials) • Results • Maternal and neonatal care – government spending per doctor visit is significantly lower in poorer regions (lowest quintile resources are 70% of highest quintile resources) • Primary education – significant variation in per-student spending which does not seem to follow a clear trend • Researchers argue that all of these issues need to be addressed for results-based budgeting to be effective in Peru

10. Research Center of the University of the Pacific (CIUP) – Peru (2 of 2) • Expenditure tracking in specific health programs • (1) Immunization and (2) Tuberculosis Prevention and Controls • Health centers in Lima Metropolitan Area • Surveys of staff and government data • Results • Complex processes of approving expenditures and obtaining funds means that facilities mitigate delays by getting credit from equipment providers, requiring staff to put in extra unpaid hours, or director pay out of pocket • Significant delays – only 1 of 14 sampled facilities had not run out of essential supplies during the previous year • Undersupplied pharmaceuticals – one facility reported undersupply of 25% of pharmaceuticals it should carry, and 18 of 33 Health Directorates lacked at least 1 pharmaceutical needed in treatment of TB (a national health priority) • Significant communication problems between Health Network and facilities – 33% and 29% of facilities reported delays in Primary Plan TB medications and Vaccination supplies respectively, while the Health Network reported no delays in either • Personnel requests not filled in many facilities (5 of 13 that requested additional doctors received none)

11. Gdansk Institute for Market Economics (GIME) – Poland (1 of 2) • Investigates the financing system in health and education • Analysis of data from Statistical Office and Ministries • Results • Misinformation among officials regarding funding sources – many politicians reported that they believed that national subsidies should cover 100% of education costs • Questionable priorities in education subsidies – subsidies to tertiary institutions increased 90% between 1999 and 2006 while subsidies as a whole fell between 2001 and 2006 • Examining the algorithm for education subsidies, GIME found that it did not take into account adverse circumstances of schools that lead to poor performance (ex – overcrowding) or school ability to draw from local funding

12. Gdansk Institute for Market Economics (GIME) – Poland (2 of 2) • Study of hospital financing and debt in Poland • In-depth analysis of previously unanalyzed data of all hospitals in the country for 2004-2006 • Case studies of hospital efforts to reduce costs and debt • Results • Hospitals operating by taking on massive debts (debt grew from PLN 6.7b to PLN 8b between 2004 and 2006) • Indebted hospitals have difficulty paying suppliers, employee social insurance contributions, and salaries, increasing incentives for doctors to leave for private sector • Although debt is high, 62.7% of hospitals had declining debt between 2004 and 2006 • Hospitals that had great success decreasing debt undertook strategies such as tailoring services to the greatest patient needs, employing doctors by contract, or receiving substantial help from local governments

13. Institute for Development and Social Initiatives (IDIS) - Moldova • Evaluation of education financing in Moldova in context of recent decentralization efforts • Interviews with local officials and school directors • Results • Found that budgeting remains highly centralized despite decentralization efforts – MoF defines salaries and draws up funding “norms” based on enrollment information from MoE, leaving local governments with little say over spending • Funds from MoF do not reflect “norms” – 29 of 30 surveyed schools reported that funding from central government does not cover costs • Gaps in funding often filled by donors or parents – parents associations funded school repairs and improvements in 25 of 30 sampled schools

14. Indo-Dutch Project Management Society (IDPMS) - India • Focused on service delivery in primary health centers in 2 districts of Karnataka (CR Nagar, Bellary) • Surveys of PHC personnel and patients • Results • Often no doctor is available for official and unofficial reasons (37% of days PHCs are open) • Replenishment of 6 common drugs can be delayed 6 to 8 months • Pharmaceutical budget of 100,000 rupees/PHC is insufficient • Recommend specific activities for NGOs to support improved healthcare service delivery

15. Institute for Policy Research and Analysis (IPAR) - Kenya • Expenditure tracking of Secondary Education Bursary Scheme in Nairobi province • Survey of principals and Constituency Bursary Fund Committees, FGDs with students • Disbursement records • Results • Delays in fund disbursement – up to 99 days delay, with only one of eight constituencies recording a lag of less than 10 days (especially problematic because beneficiaries must miss classes until funds arrive) • Potential leakage of funds – Ministry records reports 52% more beneficiaries than IPAR surveys reveal (similar result in monetary disbursement data) • Misallocation of funds – 20% of sampled schools report funds allocated to students no longer in school, 27% report students receiving double bursaries • Per-student bursaries insufficient – less than 0.5% of students in sampled constituencies receive highest bursary amount (KES 15,000) which does not fully cover cost of boarding or national schools (84% received lowest award – KES 5,000) • Recommendations include better record-keeping, timely release of funds, and shifting allocation of funds to fewer students who can actually use them

16. Institute for Policy Research and Analysis (IPAR) - Kenya • Evaluated incidence and causes of health worker absenteeism in Machakos district • Hospitals, sub-hospitals, health centers, dispensaries • Unannounced visits (am, pm) and interviews with facility directors • Results • Estimated 25% absenteeism for health workers • Estimate cost of KES 6.7m ($85,000) per month • Skilled technical workers more likely to be absent • Recommendations • Decentralize hiring/firing authority • Improve methods for monitoring absenteeism

17. Integrated Social Development Center (ISODEC) - Ghana • Examined local, regional, and national budgeting in health and education • Budget data 2001 – 2007 • Surveys and FGDs with range of stakeholders • Results • Found failure of communication between departments and agencies (horizontal and vertical) • Long-term development planning is difficult because investments in health and education are fully funded by donors (highly variable) • With one exception (education spending in Northern Region), planned expenditures consistently significantly exceed actual funding from central government • Recommend promoting monitoring of budgets by CSOs

18. Institute for Urban Economics (IUE) - Russia • Evaluated whether spending in 2 districts (Chuvash, Kalingrad) reflected stated Russian priorities in health and education • Study of budget data from Statistical office and Ministries • Results • Central government devoting increasing resources to health (2.8 to 3.2% of GDP) and education (3.5 to 3.8%) between 2004 and 2006, with regions echoing this trend • Governments shifting towards a single channel of health care spending • Regions taking on greater share of education funding • Increased spending is in part being directed towards investment in both health and education • Government still falls short of target for health spending (5% of GDP) and pre-primary education coverage

19. Centre for Regional and Information Studies (PATTIRO) - Indonesia • Evaluated specific education funding schemes • Central, Provincial, and District • Schools receive money from 7 different funds (2 operating funds and 4 investment funds from various levels, plus 1 textbook fund) • Quantitative questionnaires and qualitative interviews, FGDs in 38 schools • Results • Delays in operating funds up to 3 months • Unplanned cuts in allocated funds (for district operating funds, unplanned cuts in every school) • Allocations do not reflect needs of schools (ex – school requests money to renovate classrooms, instead gets funds to build 100m fence around 500m perimeter) • Reports of funds leaked as payoffs to “influential persons” and as “gratitude money” to bank and post office employees in transfer stage (in 12 out of 20 transfers for one operating scheme)

20. Romanian Academic Society (SAR) • Focused on study of piloted decentralization effort in education financing • Survey of general schools in urban and rural areas, mixed ethnicity • Questionnaires, interviews, and data from MoE and School County Inspectorate • Results • Expenditures do not reflect demographic changes – although 75% of surveyed schools experienced declines in students, expenditures did not decrease • Regression analysis found no good predictors of per-student spending, leading researchers to conclude that budgets are inert rather than changing to reflect needs of schools • School structure does not empower principals to lobby for resources they need – no clear channel for principals to request changes in funding from local governments • Recommendations • Shape recommendations around three possible scenarios of education spending reform – increasing the status quo, implementing decentralized spending, and linking spending with educational quality