Health Resource Tracking: An Essential Ingredient for Improved Health Governance

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Health Resource Tracking: An Essential Ingredient for Improved Health Governance February 2012

Health resource tracking – activities that measure health spending and track the flow of financial resources among different actors in the health sector – has emerged as a key priority for the global health community.

Interest in health resource tracking is no longer limited to health economists and health accountants – witness the demand for higher-quality and more timely health spending data from the High Level Forum on Health Millennium Development Goals (High Level Forum 2004), the emphasis placed on the need for tracking financial inputs for the health system by the Accountability Commission on

Women’s and Children’s Health (Ban 2010), and the growing momentum of civil society-led initiatives like the International Aid Transparency Initiative (http://www.aidtransparency.net/).

Actors like national policymakers, international development agencies, and civil society groups have become keenly aware of the importance of health resource tracking and increasingly participate in efforts to bolster systems and capacity for health resource tracking at both national and international levels. (See Box 1 for a brief description of popular resource tracking activities.)

Box 1: Health Resource Tracking Activities Resource tracking activities can be prospective (measuring planning or budgeting spending) or retrospective (measuring past spending), or both. Following are several frameworks, methods, and data systems used to collect and analyze data on the amount and flow of health funds.

At the country-level, National Health Accounts (NHA) is a widely used framework for measuring and analyzing total health spending over a defined period of time. The Public Expenditure Review (PER) provides a more detailed assessment of government spending, while the Public Expenditure Tracking Survey (PETS) analyzes how public funds flow from treasury accounts to their final point of use at the facility level. Other methods, like the National AIDS Spending Assessment (NASA), focus on specific diseases or interventions.

The Development Assistance Committee (DAC) of the Organization for Economic Cooperation and Development (OECD) maintains databases tracking foreign aid; the databases have been used by several resource tracking initiatives to measure development assistance for the health sector as a whole or priority diseases like HIV/AIDS.

Implied in this growth and diversification of interest is the recognition that health resource tracking is not solely about generating information regarding the state of health financing, but is instead a key part of improving health governance in developing countries. Timely, comprehensive, and accurate data about health spending are an essential input to several health governance functions undertaken by actors in the health sector, principally (1) evidence-based policy advocacy and policy formation, (2) sector stewardship through sound budgeting and planning, and (3) health performance management through enhanced transparency and accountability.

Evidence-based Policy Advocacy and Policy Formation

Measures of how much is being spent on health as well as information about how and on what interventions funds earmarked for the health sector are being spent is an essential ingredient for effective advocacy by interest groups and policy champions both within and outside government. Data about soaring per capita health care costs typically derived from NHA estimations have formed the basis for ongoing policy discussions about health reform in many OECD countries, the United States being the most prominent one. In developing This brief discusses the role health resource tracking countries, information from NHAs and PERs showing plays in each of these three governance areas with low government spending on health has been used by examples of resource tracking activities, tools, and methodologies used to improve health sector governance ministries of health and other stakeholders to convince ministries of finance to increase the budget allocation for in developing countries. USAID’s Health System 20/20 project has worked to institutionalize these activities and health. Such a dynamic is unfolding presently in Kenya, tools so as expand and sustain the role resource tracking where government health spending as a percentage of total government spending declined steadily from 8 in health governance. percent in 2001/02 to less than 5 percent in 2009/10 The three areas loosely mirror the stages of the policy (Health Systems 20/20 2012). This fact is routinely used process as envisioned by scholars of public policy by health sector stakeholders to press the Ministry of (Lindblom 1980). The stages track the sequence of Finance to allocate more domestic resources to health activities in the policy process from the identification (see, for example, Gishu 2012: 16). Additionally, detailed of problems and the demand for government action, information on how health funds are being allocated agenda-setting by policy advocates, the formulation of across different interventions has been used by advocacy policy alternatives and the ultimate adoption of one, the groups to lobby for changes. Also in Kenya, the Kenya implementation of the policy through government outlays Treatment Access Movement used findings from the and actions, and the evaluation of the policy’s impact.

2002 NHA HIV/AIDS subaccount that reported that Here, problem identification, policy advocacy, and policy the government spent most of its HIV/AIDS money formulation are combined under the first governance on prevention and did not contribute to antiretroviral function of evidence-based policy advocacy and formation. therapy to advocate for a line item in the budget for such The implementation phase is discussed under the second therapy (Health Systems 20/20 2002). function, planning and budgeting. The evaluation phase is In the global health context, resource tracking exercises formulated in terms of performance management. documenting how much OECD countries commit to development assistance relative to their national gross domestic product, the percentage of their commitments that are actually met, and the extent of debt forgiveness have become a lightning rod for advocacy campaigns around increasing the volume and effectiveness of international aid. The One Campaign that advocates for greater foreign aid, for example, tracks what percentage

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of pledges by G8 member countries have been realized as a way to put pressure on bilateral donors to meet their commitments (see http://www.theonecampaign. org/issues/development.html). In the health sector, the nonprofit group Medicines Transparency Alliance tracks expenditures on pharmaceuticals as a way to advocate for greater access to affordably medicines (see http://www. medicinestransparency.org/).

Following the stage of advocacy and agenda setting comes the phase of policy formation and adoption. Data yielded by resource tracking activities have also informed the adoption of policy reforms in many countries. For example, evidence revealed by the 2001/02 NHA of high out-of-pocket spending by households in Kenya led the government to reduce user fees in primary care facilities, which resulted in the number of outpatient visits increasing by over 50 percent (Health Systems 20/20 2008a). In Egypt, findings from the 2001/02 NHA, which revealed excessive household expenditures on primary care, influenced the development of the Family Health Model, an important part of the Health Sector Reform Program that systematizes an efficient and sustainable framework for primary care facilities in the country to improve the quality and accessibility of health care services. Later in 2008, the Egyptian Minister of Health and Population used data from several NHAs to highlight the continuing rise of household expenditures and advocate for expanding national health insurance.

In Rwanda, the 2006 NHA showed reproductive health spending accounted for only 6 percent of total health expenditures, which led the government to make reproductive health one of the four priority areas in the 2008 Joint Annual Health Work Plan (Health Systems 20/20 2008b).

For resource tracking information to reach its full potential for policy advocates and as an input to evidence-based policy making, several existing impediments to its use need to be addressed. First, completing a resource tracking exercise can take six to twelve months. Often findings are outdated by the time they are released, which reduces the usefulness of the information to policymakers. One solution is to streamline data collection and dissemination through

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tools like Rwanda’s Health Resource Tracker. (See Box 3 in next section.) Second, activities measuring health spending need to produce information according to categories mentioned in existing policy frameworks; exercises like the NHA will have limited utility unless they produce spending estimates for priority diseases or interventions that are of relevance to decision-makers in the country. The evolution of the NHA subaccounts for priority diseases like HIV/AIDS, malaria, and reproductive health is a good example of resource tracking methods being refined to respond to demands from country stakeholders for more detailed information on spending in priority areas.

Third, the uptake of resource tracking information for timely and informative policy analysis by local advocacy groups and policy champions remains low for a variety of reasons. In terms of supply, resource tracking data are typically contained in large technical reports issued by government agencies. Such a format is not conducive for popular consumption or use by civil society groups and policy champions within the government. In terms of demand, the media in many developing countries is unable to report these findings in interesting and informative ways. Although there are some examples of civil society organizations that have used budget and financial information for policy advocacy – for example, South Africa’s Institute for Democracy in Africa (see www.idasa.org) – many developing countries still lack a vibrant community of policy think tanks and budget analysis groups that would be the natural consumers of resource tracking data and producers of policy advocacy materials. Building local capacity for policy analysis is critical. More efforts such as Health Systems 20/20’s work with HENNET (Box 2) are called for to generate local demand for information.

Finally, most of the demand for country-level resource tracking data still comes from international agencies and partners. Advocacy and outreach efforts at ministerial meetings and regional conferences targeting high-level policymakers to convince them of the utility of resource tracking data and show them how it can be used will go a long way in increasing its use for national policy-making.

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Box 2: Making Resource Tracking Data Available for Advocacy and Policy-making Health Systems 20/20 has worked with developing countries and other development partners to think of new and creative ways to communicate resource tracking findings to key decision-makers and diverse audiences. The project’s approach to implementing resource tracking estimations emphasizes extensive stakeholder engagement at every stage of the process from inception to completion. This ensures that the analysis captures information that is relevant, and that key findings are readily assimilated by decision-makers. The project also developed a training curriculum focused on building the capacity of health officials in the government to, first, undertake policy analysis on relevant issues combining resource tracking data with other metrics of health system performance and, second, disseminate findings from resource tracking estimations and studies in more effective ways. Recognizing that the audience for lengthy government-issued reports is limited, Health Systems 20/20 assisted the NHA technical teams in Liberia, Kenya, and Namibia to prepare short brochures that highlighted the main results from the NHA. The teams undertook policy analyses on topical issues under discussion in the health sector and presented key findings in short briefs aimed at high-level policymakers and planners.

In addition to these interventions geared towards improving the supply of resource tracking information, the project implemented activities for increasing demand as well. For example in Kenya, Health Systems 20/20 partnered with the Health NGO Network (HENNET) in 2009 to organize a workshop to disseminate key NHA findings about spending in 2005/06 to HENNET’s member organizations with the aim of increasing awareness of and demand for resource tracking information.

HENNET proceeded to release a popular version of the NHA for consumption by a non-technical audience (http://www. hennet.or.ke/downloads/Kenya%20NHA%202006%20Popular%20Version.pdf). HENNET also played an active role in the data collection process during the next NHA, giving valuable feedback on the NGO survey questionnaire and facilitating a higher response rate among its members.

At the global level, the project partnered with the World Health Organization to develop the Global Health Expenditure Database (www.who.int/nha/database), a central repository for NHA data from different countries that researchers and policy advocates can readily access. The project also maintains a database that documents examples of how resource tracking data have been used by different developing countries to undertake policy analysis and/or introduce policy reforms.

Sector Stewardship Through Sound Budgeting and Planning In addition to informing high-level policy-making, resource tracking information can feed annual planning and budgeting processes undertaken by health program implementers including the government. In most lowand middle-income countries, foreign aid accounts for a large proportion of spending in the health sector. While some of the aid is channeled through the government, a significant portion is spent by the development partners themselves or NGOs that receive their funds.

This situation calls for greater coordination between development partners and the government, both in terms of aligning priorities but also more concretely in terms of each knowing the amount and purpose of the other’s health spending. For example, in Mozambique, joint government-partner planning at the provincial level allows the provincial authority to identify and address

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gaps prior to final budget decisions. This idea of joint planning inspired Rwanda to develop the Joint Annual Work Plan in 2009 to track budgeted expenditure from both government and partners. The work plan was subsequently subsumed under the Rwanda Health Resource Tracker (Rwanda Ministry of Health 2012), an online platform for collecting information on both planned and executed budgets. (See Box 3 for additional information.)

Measures of budget execution speak directly to the capacity of both government and partners to implement programs, considered a key determinant of the quality of health governance in a country (Moore and Teskey 2006). The failure of agencies to successfully spend funds allocated to them should trigger both a closer examination of financial and program management systems that may be impeding their performance as well as revisions to budget allocations. For example, the 2010 PER in Kenya revealed that execution of the development

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Box 3: Strengthening Processes for Joint Planning and Performance Management in the Health Sector In 2010, Rwanda launched a comprehensive initiative to institutionalize resource tracking in the country. At the heart of the initiative was the development of the Rwanda Health Resource Tracker (HRT), an online repository for detailed budget and expenditure data from all government agencies and partners that are implementing health programs. On an annual basis, funders use a common format to enter information about how much they plan to spend in the upcoming fiscal year as well as how much was spent in the past fiscal year, by activity. They further classify the spending according to the purpose or function, cost inputs, and district location.

The Government of Rwanda has three goals in using the HRT. First is to enhance planning in the health sector, replacing the Joint Annual Work Plan process that the government used previously to collect budget information from all partners. HRT data are now being used by national government agencies to coordinate their activities with those being undertaken by partners.

District health managers will soon access the HRT data to better manage public sector and partner spending at the local level. Second, the HRT will improve accountability in the health sector by shedding light on whether different actors are meeting their stated spending commitments, whether actual spending patterns correspond with the structure of the budget, and whether health spending is aligned with stated health sector priorities. Third, the HRT is meant to serve as a common data collection platform and repository to feed different resource tracking activities like the NHA and NASA. Thus the HRT will minimize duplicative data collection efforts by different implementers of resource tracking activities.

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budget in the health sector was as low as 45 percent. This raises questions about the capability of the health line ministries to effectively implement programs using funds allocated to them.

The utility of resource tracking information for planning, much like its usefulness to policy-making, depends critically on its timeliness. If data about planned spending are not made available until well after the fiscal year has already started, their use for joint planning is curtailed.

Similarly, real-time information about budget execution and timely information about total spending in the past fiscal year can be valuable to planners. When they are not made available at the right point in the planning cycle, their utility is diminished. The fact that development partners follow fiscal years that differ from those followed by the national government makes it additionally challenging to collect and release information about planned and executed budgets in a timely way.

Synchronizing resource tracking exercises like NHA, PER, and PETs can be more efficient and promote use for planning and budgeting by presenting a more comprehensive picture (Muchiri 2010). Zambia brought together an NHA, PETS, and Quality Service Delivery Survey to analyze the bottlenecks to achieving the health Millennium Development Goals (Picazo and Zhao 2009).

The recent recommendation made by the Accountability Commission that developing country governments and partners active in a given country should agree on a common format to report expenditure information on an annual basis would also go a long way in increasing the supply of resource tracking data for joint planning (Commission on Information and Accountability for Women’s and Children’s Health 2011). To date, most resource tracking activities have focused on past spending. Moreover, they have not been conducted on an annual basis. Building common data collection platforms for tracking public spending and expenditure by partners, both planned and executed, on an annual basis will enhance the quality of health sector planning and the stewardship of health resources.

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Health Performance Management Through Enhanced Transparency and Accountability Greater transparency and accountability in the health sector is necessary for effective health governance.

Transparency refers to open information about what different actors in the health sector are doing, whereas accountability translates into those actors being answerable for their actions. The two are closely linked, but are not the same; it is possible for governments or donors to be transparent in terms of releasing information about their actions without being accountable for their actions. In order for there to be accountability, others need to use the information to hold actors responsible.

Free, regular, and detailed resource tracking data ensure transparency and facilitate accountability. In the transparency domain, resource tracking activities that collect comparable data on health spending from different stakeholders and put them in the public domain make it possible for stakeholders to understand what is happening in the health sector and the public at large to see what different actors are doing. As previously discussed, such information can lend itself to better planning on the part of program implementers. It can empower advocates to lobby for reforms and assist decision-makers to craft effective reform programs.

Beyond these functions, the information can also allow stakeholders to hold each other accountable for following stated plans and delivering results.

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Comparing information about commitments and budgeted spending on the one hand against actual disbursements and realized spending estimates, as discussed before, can reveal problems of poor planning, inadequate financial or program management, and/ or corruption. A well-known example is education spending in Uganda, where newspapers published the amounts of grant funds allocated to individual schools, which resulted in reduced misappropriation (Reinikka and Svensson 2005: 259-267). Juxtaposing spending estimates against measures of health system output and outcomes data goes even further, cutting to the heart of program efficiency and effectiveness. This was done most comprehensively to compare health systems at the global level by the World Health Organization in the World Health Report 2000 (World Health Organization 2000). At the country-level, such comparisons of financial inputs on the one hand, versus health outputs and outcomes on the other, feature in assessments of health system performance (e.g. Health Systems Assessments implemented by the Health Systems 20/20 project as well as Health Systems in Transition reports issues by the European Health Observatory and the Asian Health Observatory).

To strengthen health governance further through greater transparency and accountability, resource tracking activities need to address existing gaps in terms of completeness, comparability, quality, and timeliness of data. Box 3 provides an example from Rwanda of an initiative to enhance health governance through comprehensive and routine resource tracking. Strong government commitment from senior leadership was a key driver of this initiative. As the above discussion of policy advocacy indicates, however, weak or nonexistent capacity on the part of media and civil society organizations to use such data limits the extent to which resource tracking information can or will be used to reinforce accountability to service users and citizens.

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Conclusion Resource tracking can contribute in a number of ways to improved health governance in developing countries. It arms decision-makers, policy advocates, health sector planners, and program implementers with critical information about financial resources for the sector, both planned and realized. These actors in turn can use the information to perform a variety of health governance functions as discussed in this brief. Therefore, institutionalizing resource tracking by strengthening systems and capacity for its production, dissemination, and use in these countries is essential for improving the quality of health governance.

Institutionalization of resource tracking entails both supply- and demand-side interventions. The former include activities that will make the generation of resource tracking information more routine and less costly, as well as make the data accessible to all stakeholders. On the demand side, interventions targeting different types of health sector stakeholders with tailored messages and training both to pique their interest in the data and increase their capacity for using the data will create a demanding clientele for resource tracking information. Resource tracking is commonly viewed as being of interest solely to health accountants and government technocrats, both by themselves and others. The fact that resource tracking data hold value for policymakers, the media, and civil society is in and of itself insufficient to inspire greater use by the latter. Technicians within government producing this information have to be convinced that there is an audience for this information outside their immediate circles, and these important stakeholder groups have to acquire the necessary skills to access and use these data.

These interventions, unified by the goal of institutionalizing resource tracking, will strengthen health governance. Better governance, in turn, will ensure both sufficiency of health funds and the efficiency of their use in order to realize the goal of maximizing health system output and improving population health outcomes.

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Health Systems 20/20 is a five-year (2006-2011) cooperative agreement (No. GHS-A-00-06-00010-00) funded by the U.S. Agency for International Development (USAID).The project uses an integrated approach to address the financing, governance, operational, and capacity constraints in a health system that impede access to and use of life-saving priority health services.

Abt Associates Inc. leads a team of partners that includes: | Aga Khan Foundation | Bitrán y Asociados | BRAC University | Broad Branch Associates | Deloitte Consulting, LLC. | Forum One Communications | RTI International | Training Resources Group | Tulane University School of Public Health

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This publication was produced for review by USAID. It was prepared by Nirmala Ravishankar for the Health Systems 20/20 project.

DISCLAIMER:The author’s views expressed here do not necessarily reflect the views of the United States Agency for International Development or the U.S. Government.

February 2012 For more information about Health Systems 20/20 please contact: Health Systems 20/20 | Abt Associates Inc.| www.abtassociates.com 4550 Montgomery Lane | Suite 800 North | Bethesda, MD 20814 | USA E-mail: info@healthsystems2020.org | www.healthsystems2020.org

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