Overview of existing resource tracking efforts, methodologies and findings Teresa Guthrie Centre for Economic Governance and AIDS in Africa

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

3  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?

4  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?

5 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 analysis Using budget analysis as a resource-tracking tool

6 Uses 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

7 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

8 Budget Monitoring, Expenditure Analysis and Resource Tracking Assessment of Resource Need – costing analysis Budget Allocations – indication of intended PUBLIC expenditure Actual Expenditure – execution of budget. Can include all sources of funds and by all service providers Public Private Donor Budget Monitoring Process Actual amounts Revenue & tax Sector analysis Expenditure Analysis Process/finance channels Actual amounts Output analysis – interim indicators comparing with objectives of expenditure Outputs Efficiency Effectiveness Quality Outcome analysis – long-term indicators. Impact assessment Life years saved Quality of life Reduced prevalence rates Causal link Effectiveness (CEA/CBA/CUA) Your use of the data will influence all these aspects

How much was spent How much was allocated How 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 analysis toExpenditure Estimates Linking Resource Need Estimates to Allocation analysis to Expenditure Estimates

10 Existing Health & HIV/AIDS Resource 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

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

12 Source: OECD/UNAIDS special study: Aid Activities in Support of HIV/AIDS Control for Development aid for HIV/AIDS: How much is going to which countries? Nigeria Kenya Uganda Zambia Ethiopia South Africa Mozambique Ghana Tanzania Zimbabwe Total million USD Per capita USD Total million USD Per capita USD

13 2. HIV/AIDS Budget studies

14 Civil Society groups supported to undertake Health and HIV/AIDS Resource Tracking 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% 2000/12001/22002/32003/42004/52005/6 Mozambique South Africa Kenya Abuja target Namibia – Health specific Namibia - Total for MoHSS Source: Guthrie & Hickey, ABU, Idasa. Are African states meeting the Abuja declaration?

0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 2000/12001/22002/32003/42004/52005/6 South Africa Mozambique Kenya Africa ~ HIV/AIDS allocations as share of total health expenditure Source: Guthrie & Hickey, ABU, Idasa.

17 Source: Kioko in Guthrie & Hickey, National Aids Resource Envelope, (2000/ /06) 0 2,000,000 4,000,000 6,000,000 8,000,000 10,000,000 12,000,000 14,000, / / / / / /06* Kshs Other (pvt, NGOs, CBOs, FBOs) Public Sector (government & donors) Bilateral/ Multilateral/NGOs Total HIV/AIDS Expenditure in Kenya by Source

18 NB: Does not include funds from provinces' own budgets ,000 1,500 2,000 2, /12001/22002/32003/42004/52005/62006/7 R million (nominal) Dept. of Public Service & Admin. and Dept. of Science & Tech. Social Development: HIV/AIDS Programme (including condtl grants) Education: HIV/AIDS condtl grant Health: HIV/AIDS and TB Sub- programme includes condtl grant South Africa – HIV/AIDS allocations by sector Source: Guthrie & Hickey, ABU, Idasa.

19 Challenges/ limitations of the 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.

20 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.

21 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.

22 3. NHAs NAAs NASAs

23 1. Foreign or international or external IFIs, bilateral, multilateral, intl corporations, intl NGOs, Rest-of- World households 2. Public Central government, sub-national government, social security 3. Private 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 measures funds from three main financing sources:

24 Flow of resources from origin to end users: reconstruction of transactions AC Source Provider Functions B Budgetary ItemsTarget Groups Non Specific

25 NASA Spending Categories/ Priorities

26 NASA Treatment Components

27 NASA Beneficiaries of Spending

28 Private Contributions to HIV/AIDS – PLWHAs carry a 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).

29 Source: PHRplus - NHA, 2002.

30 NAAs ~ HIV/AIDS per capita expenditures LAC and selected African countries. PPP- USD$, 2002/3. (Pre-GF) Burkina Faso Ghana Kenya Rwanda Zambia PPP$ 7.79 PPP$ 8.12 PPP$10 PPP$12 PPP$ 15

31 NHAs – Analysis of Sources of Expenditure on Health Source: Nandakumar, A.K., Bhawalkar, et al Synthesis of Findings from NHA Studies in Twenty-Six Countries. PHR+ Project. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Ethiopia Kenya Malawi Mozambique Rwanda South Africa Tanzania Uganda Zambia Zimbabwe MENA LAC Percent of total health expenditure Donor Private Public

32 Gaps in the existing information 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

33 Expanding & harmonising approaches 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

34 Expanding & 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.

35 Conclusion 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!

36 Thank you! Thank you! For more information contact: Teresa Guthrie Centre for Economic Governance and AIDS in Africa Tel: Fax: