1 Does budget support (still) work the way it has been designedDoes budget support (still) work the way it has been designed ? Experience from Mozambique, Rwanda and Uganda. Health Sector Days – 04/12/2014
2 Outline Background Scope and objectives MethodologyComparative analysis – key country data Comparative analysis – key indicators of health financing and health outcomes Comparative analysis of preconditions & enabling factors for budget support Conclusions
3 1. Background Regional seminar in Kigali in August 2014: innovative form of backstopping and peer to peer technical support from a regional perspective. Continuum with Budget Support seminar in Kampala in May 2013 (reflecting on the effectiveness of the BS modality in rapidly changing international and country contexts) Decline of BS overall Shift from General BS to Sector BS or Pooled Funds and result-based financing models
4 2. Scope and objectives Focus: budget support & basket funding in the health sector Draw comparisons across the region and assess the effectiveness of our BS programmes in different country settings Preconditions/enabling factors for BS, design of BS « package », quality of policy dialogue, role and profile of expertise. Confront different modalities considered as budget support (SBS vs. basket fund) Highlight good practices at country level Review tools, methods of analysis and providing feedback to one another Produce joint deliverables on technical analysis and recommendations to feed into the revision of the Budget Support & Basket Fund Vademecum
5 3. Methodology: practical arrangementsCollective brainstorming for formulation of ToR, expectations, a clear set of outputs – with remote support from EST Selection of most relevant topics to be covered Standardised templates for PPT presentations on selected topics, allowing for comparative analysis Extended invitation to other Belgian actors (Attachés, TAs) and Development Partners (Unicef, EU, KfW) to enrich discussions Field visit to Gakenke district government and hospital: link strategic discussions with a visit to the decentralised and service delivery level Link with HQ for insight into ongoing strategic discussions (4MC, future of BS?)
6 3. Methodology: selection of relevant topicsAnalysis of sector budgets and country systems in the context of PFM and Decentralisation Additional insight into specific topics: HRH (gaps, wage bill) Performance-Based Financing Public-Private Partnerships Assessing the external audit function and domestic accountability mechanisms
7 3. Methodology: portfolio under review « budget support as a package »Mozambique Flanders Cooperation contributes to Health sector-wide multi-donor basket fund, (amount?) TA in Public Financial Management (PFM) delegated to BTC Rwanda Sector Budget Support, € 32 Million (ICP ) Capacity Development Pooled Fund (HRH), € 2 million 1 Public Health expert and 1 PFM expert Uganda Sector Budget Support, € 10 Million (ICP … ) + € 6 million in the pipeline (ICP …)
8 4. Comparative analysis: key country dataPopulation Life expectancy at birth Access to electricity HDI ranking 2014 Mozambique 24.3 M (30.4 p/km²) 53 0.393 (ranking: 178) Rwanda 10.5 M (451 p/km²) 64.5 18% 0.506 (ranking: 151) Uganda 37.5 M ( X p/km²) 0.484 (ranking: 164)
9 5. Comparative analysis – key health outcomes indicators financing and
10 5. Comparative analysis – key health outcomes indicators
11 5. Comparative analysis – key health outcomes indicators financing and
12 5. Comparative analysis – key health outcomes indicators financing and
13 5. Comparative analysis – key indicators health financing and outcomes
14 5. Comparative analysis – key indicators health financing and outcomes
15 5. Comparative analysis – key indicators health financing and outcomes
16 5. Comparative analysis – key indicators health financing and outcomes
17 6. Comparative analysis pre-conditions for BSPolitical commitment to the health sector MOZ Long-lasting commitment to the health sector as a priority sector (90s). Pooled fund mechanism ‘PROSAUDE’ (2003) for earmarked support to the sector. Recent increase in internal funding to the sector reducing dependency on donors’ support. RWA Significant investments in budget allocations, policy development and implementation. A key factor in the success in achieving key health outcomes targets. High commitment to achieving the Health MDGs. UGA Gradual priority shift from social to productive sectors reflected in decreasing budget allocations to the health sector. Decreasing level of commitment to the sector is a key determinant in the reduction in the pace in achieving key health outcomes.
18 6. Comparative analysis pre-conditions for BSHigh level dialogue on BS MOZ Early establishment of the General Budget Support (GBS) platform. Dialogue recently weakened by two major crises (2009/10 and 2013/14). RWA Prior to 2012, the Budget Support Harmonisation Group convened on a regular basis. Formal dialogue structure dissolved in 2013 as a direct result of aid crisis. Discussions on budget was absorbed at highest political level between Government and all Heads of Cooperation with a smaller level of representation of BS donors over time. UGA Structured high level dialogue on budget support in place since 1998. Gradual erosion of policy dialogue linked to decreasing alignment of DP and GoU priorities (in particular on social sectors). 2013/14: collapse of Joint Budget Support Framework linked to corruption scandals. New framework for dialogue ‘post-JBSF’ yet to be fully operationalized.
19 6. Comparative analysis pre-conditions for BSCritical mass of donors engaged in BS at sector level MOZ Critical mass (List??) of donors supporting the health sector basket fund ‘PROSAUDE‘ since 2003. RWA 3 bilateral development partners over the period Belgium now remains the only SBS bilateral provider. New players and new modalities in the picture: Global Fund providing result-based SBS and EU providing multi-sector SBS for nutrition. UGA Between 2-6 development partners involved over the period 2005/06 to 2011/12. Belgium now remains the only SBS provider.
20 6. Comparative analysis pre-conditions for BSSector dialogue MOZ Sustained good level of partnership. Policy dialogue growing stronger and more elaborated, supported by increased internal financial investment in health. RWA Continuous reform is stretching out MoH staff and limiting ability to engage in policy dialogue proactively. Limited appetite from non SBS donors to engage in budget and accountability issues. UGA Good quality of sector policy dialogue with regards to policy development. Dialogue on budget and accountability gradually constrained by GoU’s prioritization of productive sectors + the smaller number of donors engaged in Sector Budget Support.
21 6. Comparative analysis pre-conditions for BSPFM / transparency, accountability and corruption in the public sector MOZ Recognized as a good story of early PFM reform, with slower progress over time. Issues of capacity and a lack of appropriation by line ministries of centrally-driven reforms. Positive trajectory of reforms in the health sector. RWA PFM reform ongoing since 2008. Positive evolution, with some weaknesses remaining in internal control and financial reporting. UGA PFM reforms since 2007 with good achievements in terms of system development and roll-out. Significant compliance / enforcement gap has been offsetting progress in system development. Health sector performs comparatively low.
22 6. Comparative analysis pre-conditions for BSPFM / transparency, accountability and corruption in the public sector
23 6. Comparative analysis pre-conditions for BSPFM / transparency, accountability and corruption in the public sector
24 6. Comparative analysis pre-conditions for BSTransparency and inclusiveness of the budget process MOZ Positive evolution in budget transparency, including comprehensive budget execution reports. Weak dialogue entry points into planning and budgeting cycle. RWA Budget transparency is a matter of concern in Rwanda (Open Budget Index, 2012) Information in budget execution reports is incomplete (domestic vs. external funds), highly aggregated, and barely discussed. UGA Good presentation and availability of budget documents. In recent years, decline in Government’s openness and engagement with external agents in dialogue on budget issues.
25 6. Comparative analysis pre-conditions for BSEffectiveness of the external control function MOZ Firm improvements in audit coverage and quality. But external oversight remains weak overall. ~ RWA Significant improvement of the audit coverage, growing automony of the OAG, but full audit reports are difficult to access. Dialogue on audit is weak as Government reluctant to engage with DPs on audit issues. UGA Substantial improvements in the quality and coverage of annual audit reports by the Office of the Auditor General in the past 10 years. External oversight remains incomplete due to serious bottlenecks at Parliamentary level. Sector dialogue on audit issues has been weak in recent years but showing signs of recovery.
26 6. Comparative analysis enabling factor for BSBTC programme approach of health support interventions MOZ Sector-wide basket fund HRH project RWA SBS and Capacity Development pooled fund Institutional support programme UGA SBS Institutional Capacity Building project in Leadership & Management Support to the Private Not-for-Profit sub-sector (2014)
27 7. Conclusions Political commitment to the sector is the most critical factor supporting the effectiveness of budget support. The impact of budget support is most visible where donor support translates into increased resource allocations to the sectors supported. The existence of a critical mass of donors engaged in BS at sector level contributes to: Maximizing policy leverage of the budget support instrument, Legitimizing dialogue on budget and accountability. The existence and quality of frameworks for high level and sector policy dialogue are significant factors for the effectiveness of policy dialogue, but donors’ ability to leverage policy making should not be overestimated. The degree of alignment of donor and Government priorities for the sector is a key determinant of the effectiveness of policy dialogue.
28 7. Conclusions PFM performance is a critical factor for the effectiveness of budget support. Experience from PFM reforms in the region tend to show that reforms tend to focus on system development and roll-out, but not enough on issues of capacity, compliance and enforcement. Decentralisation? Programme approach Good coordination and synergies with other aid modalities is critical for a sound and credible policy dialogue Active involvement of BS experts in the dialogue structure contribute to Health System Strengthening in areas of HRH, Health Financing, Planning-HIS_M&E, Medical Infrastructure and Technology, action research,