Overview of existing resource Overview of existing resource tracking efforts, tracking efforts,

methodologies and findingsmethodologies and findings

Teresa Guthrie

Centre for Economic Governance and AIDS in Africa

22

Presentation outlinePresentation outline

Why track budgets and expenditure?? Some definitions Existing efforts Findings and limitations Gaps in the information Harmonisation of approaches Conclusion

33

Govt is powerful actor in national economy so how it spends its money and how it raises money is a large determinant of health of the economy

Govt revenue and expenditure plans can potentially have powerful redistributive and developmental impact

Relative openness of budget processes and systems are key indicator or influence on degree or nature of democracy in the country

Why do government budgets matter?Why do government budgets matter?

44

Fundamental tool in implementation of public policy sets out the allocation of public resources.

More telling indicator of the priority accorded to health (or any issue) than policy or legislation

National budget is key to sustainability of any government programme

Informed budgets and funding mechanisms for health therefore enhance ability of governments to plan and implement health interventions effectively.

Why track budgets?Why track budgets?

55

Adequacy: How much is budgeted? Vs Need?

Priority: How does the budget for this purpose compare to resources spent in other areas?

Progress: Is government’s response on this issue improving?

Equity: Are resources being allocated fairly?

Using budget analysisUsing budget analysisas a resource-tracking toolas a resource-tracking tool

66

Uses of Resource TrackingUses of Resource Tracking Resource tracking identifies and measures:

All sources of funds – public, private and external Providers of services (recipients of funds, public &

private) Actual expenditure on all services Beneficiaries and outputs

Identification of what resources are available, so as to ascertain the resource gap

Mobilizing more resources to fill gaps Allocative efficiency measurement To measure trends over time – changing

priorities. Informs policy decisions

77

Uses of Resource Tracking cont.Uses of Resource Tracking cont.

Advocacy – evidence = power! Addressing equity of access to services Distinguish between Real Aid and

Phantom Aid To monitor issues of additionality of

financial and human resources To identify absorption capacity problems

and bottlenecks

88

Budget Monitoring, Expenditure Budget Monitoring, Expenditure Analysis and Resource Tracking Analysis and Resource Tracking

Assessment of Resource Need – costing analysis

Budget Allocations – indication of intended

PUBLIC expenditure

Actual Expenditure – execution of budget. Can includeall sources of funds andby all service providers

PublicPrivateDonor

Budget MonitoringProcess

Actual amountsRevenue & taxSector analysis

Expenditure

Analysis

Process/finance channels

Actual amounts

Output analysis – interim indicatorscomparing with

objectives of expenditureOutputs

EfficiencyEffectiveness

Quality

Outcome analysis – long-term indicators.Impact assessment

Life years

saved

Quality of li

fe

Reduced prevalence

rates

Causal link

Effectiveness

(CEA/CBA/CUA)

Your use of the data

will influence all

these aspects

How much was spentHow much was

allocatedHow much is needed

•Through government•Public•Foreign•Private

•In strategic programs•Targeted IEC•Condoms•PMTCT•STI treatment•VTC•ARV treatment•IO treatment•Palliative services•Social Impact Mitigation•Staff training•Research

•Through private orgs/NGOs

•At global level•At national level

•MOH•Other ministries•NGO, CSO, CBO

•At province level•Tertiary, Secondary•Primary level•NGO, CSO, CBO

•At local level

•In strategic programs•Based on need (idealistically?)•Currently covered (reality?)•Financial / Programmatic gaps

Linking Resource Need Estimates to Allocation Linking Resource Need Estimates to Allocation analysis toanalysis to Expenditure EstimatesExpenditure Estimates

1010

Existing Health & HIV/AIDS Existing Health & HIV/AIDS Resource Tracking EffortsResource Tracking Efforts

National Health Accounts (WHO NHAs) – sub-analysis on HIV/AIDS expenditure

Budget analysis studies of allocations – AIDS Budget Unit, FUNDAR, IBP, ActionAid, ELBAG, CSPR group, many civil society groups

OECD-DAC data base and NIDI Resource Flows Project for HIV/AIDS & reproductive health – donor assistance only

National AIDS Accounts (Stand alone NAAs) – only HIV/AIDS expenditure - SIDALAC

National AIDS Spending Assessments (NASAs) - only HIV/AIDS expenditure - UNAIDS

1111

1. OECD-DAC database of 1. OECD-DAC database of HIV/AIDS donor HIV/AIDS donor commitments commitments

1212

Source: OECD/UNAIDS special study: Aid Activities in Support of HIV/AIDS Control for 2000-2002.

Development aid for HIV/AIDS:Development aid for HIV/AIDS:How much is going to which How much is going to which

countries?countries?91.2

28.6

0.7

4.1

0.8

2.2

0

10

20

30

40

50

60

70

80

90

100

Nigeria

Kenya

Ugand

a

Zambia

Ethiop

ia

South

Africa

Moz

ambiq

ue

Ghana

Tanza

nia

Zimba

bwe

Tot

al m

illio

n U

SD

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Per

cap

ita

US

D

Total million USD 2000-2002

Per capita USD 2000-2002

1313

2. HIV/AIDS Budget studies2. HIV/AIDS Budget studies

1414

Civil Society groups Civil Society groups supported to supported to

undertake Health and undertake Health and HIV/AIDS Resource HIV/AIDS Resource Tracking in AfricaTracking in Africa

CEGAA works with UNAIDS, OSI and ActionAid in numerous African, East European and Asian countries.

International Budget Project supports budget advocacy throughout the world.

(Public Health as share of total expenditure)

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

2000/1 2001/2 2002/3 2003/4 2004/5 2005/6

Mozambique

South Africa

Kenya

Abuja target

Namibia – Health specific

Namibia - Total for MoHSS

Source: Guthrie & Hickey, 2004. ABU, Idasa.

Are African states meeting Are African states meeting the Abuja declaration?the Abuja declaration?

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

2000/1 2001/2 2002/3 2003/4 2004/5 2005/6

South Africa

Mozambique

Kenya

Africa ~ HIV/AIDS Africa ~ HIV/AIDS allocations as share of total allocations as share of total health expenditurehealth expenditure

Source: Guthrie & Hickey, 2004. ABU, Idasa.

1717 Source: Kioko in Guthrie & Hickey, 2004. National Aids Resource Envelope, 2003.

(2000/01-2005/06)

0

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

2000

/01

2001

/02

2002

/03

2003

/04

2004

/05

2005

/06*

Ks

hs

Other (pvt, NGOs, CBOs,FBOs)

Public Sector (government &donors)

Bilateral/Multilateral/NGOs

Total HIV/AIDS Total HIV/AIDS Expenditure in Kenya by Expenditure in Kenya by

SourceSource

1818

NB: Does not include funds from provinces' own budgets.

0

500

1,000

1,500

2,000

2,500

2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/7

R m

illio

n (n

omin

al)

Dept. of PublicService &Admin. andDept. ofScience &Tech.

SocialDevelopment:HIV/AIDSProgramme(includingcondtl grants)

Education:HIV/AIDS condtlgrant

Health:HIV/AIDS andTB Sub-programmeincludes condtlgrant

South Africa – HIV/AIDS allocations by South Africa – HIV/AIDS allocations by sectorsector

Source: Guthrie & Hickey, 2004. ABU, Idasa.

1919

Challenges/ limitations of Challenges/ limitations of the budget studiesthe budget studies

General Budget challenges: Inaccessibility and unavailability of budget

data (for budgets generally and HIV/AIDS specifically)

Previously centralised governments – access difficult & general lack of CSO participation.

Little disaggregation in budget documents. Recorded budget allocations are rarely the

actual expenditure & audited figures not easily available.

Varying budgetary and accounting systems – undermines comparability between countries.

2020

Issues specific to HIV and Aids: Lack of HIV/AIDS specific line-item in formal

budget documents. Lack of standardized classifications and

definitions. Global interest in donor allocations to HIV and

Aids (mostly not indicated on budget) Countries lack central database of donor funds. Desk review alone of formal budget documents

is insufficient to obtain adequate data – estimates of expenditure required.

Challenges cont.Challenges cont.

2121

Methodological issues: Budget allocation analysis insufficient

– need expenditure estimates, and output analysis.

Limited analysis of the services provided (nothing on target groups).

Demand not only for budget allocations, but to also identify outputs and assess the impact of expenditure.

No district level analysis – but demanded by NGOs.

Challenges cont.Challenges cont.

2222

3. NHAs NAAs NASAs3. NHAs NAAs NASAs

2323

1.1. Foreign or international or externalForeign or international or external• IFIs, bilateral, multilateral, intl corporations, intl NGOs, Rest-

of-World households

2.2. PublicPublic• Central government, sub-national government, social

security

3.3. PrivatePrivate• Households, out-of-pocket expenditure (OOPE), NGOs,

insurance

Globally, bilateral donors and multilateral agencies are the largest funding streams, although the size of these streams varies significantly by region.

NASA identifies and NASA identifies and measures funds from three measures funds from three

main financing sources:main financing sources:

2424

Flow of resources from origin Flow of resources from origin to end users: reconstruction of to end users: reconstruction of

transactionstransactions

A C

Source Provider

Functions

B

Budgetary Items Target Groups

Non Specific

2525

NASA Spending Categories/ Priorities

Proportional Spending Priorities 2005

0%

20%

40%

60%

80%

100%

Public sector Internat.Orgs

FN 8..HIV- and AIDS-Related Research

FN 7..Community Development &Enhanced Environment

FN 6..Social mitigation

FN 5..Human Resources for HIV andAIDS activities

FN 4..Prog.Devmt & HSS strengthening

FN 3..Orphans and Vulnerable Children(OVC)

FN 2..Treatment and care components Total

FN 1..Prevention Programmes

2626

NASA Treatment Components

PUBLIC Treatment Expenditure 2005

37%

16%1%

40%

6% Antiretroviral therapy.

Prophylaxis for OpportunisticInfections - mainly IPT

Treatment of OpportunisticInfections.

Hospital treatment and care.

Palliative care (incl. HBC)

2727

NASA Beneficiaries of Spending

Beneficiaries by Agent (2005)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Public sector Private sector International Orgs.

PLWHA Most at Risk Pops. Vulnerable Groups.

Accessible Pops. Gen.Pop (non-targeted) Other Pops.

2828

Private Contributions to Private Contributions to HIV/AIDS – PLWHAs carry a HIV/AIDS – PLWHAs carry a

large share large share Burkina Faso - households contribute 14% of

the total expenditure on AIDS - primarily used for traditional healers (70%) and purchasing pharmaceuticals (29%) (NAA, 2003).  

Zambia – HH contributed 29% of expenditures through out-of-pocket spending. Government = 17%. Donors and cooperating partners = 46% (NHA, 2002).

Rwanda - HH contributed 16% of expenditures through out-of-pocket spending. Government = 8%. Donors and cooperating partners = 75% (NHA, 2002).

2929

2002Total HIV/AIDS expenditure = US$10.3M

Paid by Households= US$1.6M

NHA Rwanda: Households are paying a large shareof total HIV/AIDS expenditure.

Other private

1%

Public8%

Households16%Donors

75%

Source: PHRplus - NHA, 2002.

3030

NAAs ~ HIV/AIDS per capita NAAs ~ HIV/AIDS per capita expenditures LAC and selected expenditures LAC and selected African countries. PPP-USD$, African countries. PPP-USD$,

2002/3. (Pre-GF)2002/3. (Pre-GF)

0.00 2.00 4.00 6.00 8.00 10.00 12.00

BoliviaGuatemala

MéxicoChile

ParaguayEl Salvador

R DominicanaPerú

BrasilPanamá

NicaraguaCosta Rica

ArgentinaUruguay

Honduras

Q1

Q2

Q3

Q4Haiti

Burkina Faso

Ghana

KenyaRwanda

Zambia

PPP$ 7.79

PPP$ 8.12PPP$10

PPP$12

PPP$ 15

3131

NHAs – Analysis of Sources NHAs – Analysis of Sources of Expenditure on Healthof Expenditure on Health

Source: Nandakumar, A.K., Bhawalkar, et al. 2004. Synthesis of Findings from NHA Studies in Twenty-Six Countries. PHR+ Project.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ethio

pia

Kenya

Mala

wi

Moz

ambi

que

Rwanda

South

Afri

ca

Tanza

nia

Ugand

a

Zambi

a

Zimba

bwe

MENA

LAC

Per

cent

of

tota

l hea

lth

expe

ndit

ure

Donor

Private

Public

3232

Gaps in the existing Gaps in the existing informationinformation

Local government expenditure (district level) Comprehensive databases of external sources

(at international and national levels) Limited disaggregation by function (service

provided) Limited: indirect /out-patient / Home-Based

Care Limited household expenditure (different

methods) Limited disaggregation by gender and age Limited analysis of expenditure on non-health

HIV/AIDS activities Outputs and outcomes – assessment of quality of

goods and services production level, not only resource consumption level

Challenge – standardizing classifications and definitions – to ensure cross-country comparison

3333

Expanding & harmonising Expanding & harmonising approachesapproaches

Necessary for cross-country comparisons and international acceptance of findings

Therefore approaches should: Provide an inventory of ALL resources for health or

HIV/AIDS ~ public, private, international ~ (allocated budgets and actual expenditures) OR select one or more and undertake comprehensively

Standardised definitions and classifications for all the functions and categories – suggest using NHA (for health) and NASA (for HIV/AIDS) guidelines

Provide internationally comparable reports - the breakdown of tables, the content of categories and the methods of calculation must be harmonized & internally consistent

3434

Expanding & Expanding & harmonising cont.harmonising cont.

Tracking all transactions and all services provided, down to district level (where feasible).

Identification of the beneficiary groups of all services provided.

UNAIDS suggests that the methods should be compatible with the SNA /NHA / NASA systems developed over the last 30 years.

Measurement of actual outputs and outcomes, and effectiveness analysis where possible.

Broadening the network of countries and organisations involved in health and HIV/AIDS resource tracking globally.

3535

ConclusionConclusion Attention on improving economic

governance, accountability, transparency, challenging the size of the pie to health and HIV/AIDS.

Increasing efforts by governments and civil society to track the resources flowing to health and HIV/AIDS and their utilization.

Financial management and reporting systems are poor, and formal budget figures are insufficient to give the whole picture, therefore investigative research and mobilisation required!

The power is where the money is!

3636

Thank you!Thank you!

For more information contact:Teresa GuthrieCentre for Economic Governance and AIDS in Africa Email: teresa@cegaa.orgguthrieteresa@yahoo.comTel: +27-82-872-4694Fax: +27-88-021-425-2852