Funds

Facility budgets provide an outline for how a given amount of money received from a particular source is intended to be spent. Ideally, budgets should be a tool to proactively plan for future activities and track the use of funds in real time. BudgetA document that outlines forecasted revenue and planned expenditure for an entity (government, subnational unit, or health facility) over a defined period of time. Budgets indicate how funds are meant to be allocated to achieve certain objectives. preparation exercises help facilities estimate how much funding they will have available and how they will use that funding. In larger PHC facilities with authority to manage their own finances, budget preparation is an essential component of planning (such as what kinds and how many medicines and supplies to buy, which staff to hire, and how to meet the evolving needs of the patients and communities the facility serves).  Many smaller government-owned PHC facilities may not have this authority – staff allocations may be decided at a higher level and medicines provided in-kind – and their budgets may cover only on facility operational costs or use of internally generated funds.

Challenges with health sector budget formulation that affect funds availability at facilities

In many contexts, facility budgets are determined as part of a broader or national health sector budget formulation process. National health budgets may be set by referring to historical spending levels – what was the budget last year and did that money get spent? – and often focus on determining the funds required for service inputs like personnel, medicines, and supplies. However, historical budgets may not accurately reflect optimal spending patterns or current population health needs. Focusing on inputs or line items may distract from what outputs and outcomes are being achieved with funds allocated. 

Common challenges in health budget formulation processes that can impact funds availability at the facility level include ¹: 

• Variability in annual amounts allocated to the health sector by Ministries of Finance or legislatures
• Weak evidence on actual costs and unrealistic revenue projections, leading to lack of health budget credibility
• Budgets developed from historical spending patterns with little connection to annual operational plans, making it challenging to translate health sector priorities into budget allocations. 

Improving how budgets are set

Health sector budget allocations should be set utilizing need-based, empirical factors, including population size, demographic characteristics like age and fertility rates, and the burden of disease and associated treatment costs. Countries can improve the budgeting process by moving to a combination of Top-down budgetingBudgeting process in which a central (national) authority determines resource allocations based on revenues available. (where the central budgeting authority determines resource allocations based on revenues available) and Bottom-up budgetingBudgeting process in which health facilities or other subnational units estimate the budget needed to meet local service delivery needs. (where facilities estimate the budget needed to meet local service delivery needs). Easy-to-understand allocation formulas with a system of financial transfers for poorer areas are recommended. ¹ To develop evidence-based allocation criteria, countries can use benefit incidence analysis to understand how much poor areas benefit from government spending, relative to wealthier groups. ² (For further reading on benefit incidence analysis and when it can be utilized, see How to do (or not to do) a benefit incidence analysis.

Using output-based budgeting (also known as “performance budgeting”, "performance-based budgeting", “Program-based budgetingDeveloping budgets based on the resources needed to achieve program objectives (or produce desired outputs or results).", “program-based budgeting” and “budgeting for results”) ³ may also improve the responsiveness of budgets to changing local health needs. Output- or program-based budgets are oriented around achieving specific results and the anticipated resources needed to achieve those results. This type of budget orientation can help hold facilities accountable for delivering outputs (such as successful prevention, diagnosis and treatment of patient conditions), rather than simply spending inputs. ⁴ It shows elected officials “what will be accomplished with the money, as opposed to merely showing that it has been used for the purchase of approved input”. ³

For further information on budgets and how they can impact performance, see Budgeting for Health.
 

To support high-quality primary health care delivery, funds need to reach frontline facilities in a timely and predictable fashion, and in full. But in many LMICs, challenges with getting public funds to lower-level facilities are common.  Personnel, operational, and capital funds often reach facilities in different ways and have different challenges associated with disbursement. 

Challenges with getting funds to frontline facilities

Common challenges to getting funds to facilities include leakage in funds transfers along the chain from central, regional, and local levels of government to facilities; and delays in disbursement. ⁵  Public expenditure tracking surveys (PETS), which carefully triangulate what proportion of disbursed public funds are received by lower-level facilities, often reveal delays and leakages that prevent facilities from receiving operational funds. In Chad, for example, only 18% of the non-wage recurrent budget reached the regional level, and front-line providers received less than 1% of funds. ¹  In Ghana, a survey found that only 20% of non-salary funds reached health facilities, and in Tanzania, the estimated leakage rate – meaning funds either disappeared or were not used as budgeted – of non-salary funds was 41%. ⁵ For a brief overview of PETS and how to conduct one, see: Economic and Social Tools for Poverty and Social Impact Analysis: PETS.

Budget transfer systems that require multiple steps in the payment process between the Ministry of Finance and facilities can create delays in funds reaching facilities, whether due to complex administrative procedures or leakage as funds move through the system.  Such delays can translate into seemingly low budget execution rates (the proportion of budgeted funds which are spent by the end of the fiscal year) for the health sector. In Nepal, for example, approximately 20% of the overall 2012 health budget was disbursed in the final quarter of the year, resulting in District Health Officers under-utilizing funds by 20%. ² Low budget execution rates, in turn, can jeopardize future allocations from the Ministry of Finance, which might blame the underspend on inefficient facility management rather than on late disbursements. 

Delayed or irregular payments also have a negative impact on health workers and can lead to demotivation, mistrust, and absenteeism. If providers are not paid, they may charge informal payments to patients or refer patients in public facilities to their own private clinic in an effort to make up for lost wages. ⁵ Over the long term, remuneration challenges can make health workers less interested in taking a government-funded health care position in the first place, contributing to staffing shortages in the public sector. 

Improving the flow of funds

Successful budget execution entails coordinating and streamlining the processes that lead to effective funds transfers from the national treasury to the Ministry of Health and then to districts and health providers. Simplifying payment systems by reducing the number of layers through which disbursements must flow can increase the timeliness of payments and reduce leakages. Establishing facility bank accounts and making direct payments to facilities can more efficiently move funds to front-line providers (see further discussion below). This will require increasing facilities’ Financial managementSystems and processes at the facility level to track revenues and expenditures, ensure that resources are not wasted, and ensure that desired results are achieved capacities to manage, track, and report on funds provided. 

Addressing central-level cash management problems may also be necessary. Countries that use cash budgeting processes (meaning cash must be available before the budget is disbursed) often experience unpredictable funds availability. If the central budget is unrealistic due to limited cash at hand, Ministries of Finance often engage in cash rationing. Remuneration can be delayed for many months due to liquidity problems and then is often disbursed in larger sums towards the end of the fiscal year. ⁵ Improvements in timely, regular health worker payments are likely to require budget process strengthening and improvement in budget execution at the central level.
 

Facility Financial managementSystems and processes at the facility level to track revenues and expenditures, ensure that resources are not wasted, and ensure that desired results are achieved refers to systems and processes at the health facility level to track and manage revenues (funds received from government transfers, insurance payments, and patient fees) and expenditures (outlays on personnel and other inputs). Strong financial management systems allow facilities and the health system overall to manage and track funds effectively, comparing spending to estimated budget allocations and adjusting as needed. They also help identify when underperformance is due to inefficiency or insufficient funding and plan for future spending needs.  

Common components that health facilities need to manage include personnel, operations, and capital spending. 

• Personnel (also called remuneration) includes staff salaries and fringe benefits. Staff who are government employees may be hired and paid directly by the central or subnational government. Sometimes the civil service is entirely administered by another ministry outside the health sector – for example, a Ministry of Labor – and their costs will not be handled by the facility at all. In some contexts, health facility managers can hire additional contract staff to cover for staff shortages or fill specific positions (e.g. laboratory services). These costs would be managed directly by the facility.  
• Operations include the non-personnel inputs required to run the facility and can include: 
  • Medicines, supplies and equipment. These are either procured centrally and distributed in-kind, or facilities may receive funds directly and manage their own procurement. 
  • Community outreach activities. These would include allocations for vehicles and fuel costs, educational supplies, etc.
  • Maintenance, utilities, and sanitation.
• Capital spending includes infrastructure improvements. These may also be managed centrally, sometimes by a separate public works ministry. 

Challenges with facility financial management

Many primary care facilities have only limited authority to manage their own funds.  They may not have a facility bank account that they can access directly; their staff may be managed and paid centrally and they may have little ability to hire and fire staff locally. Medicines and supplies may be provided in kind, and facility managers may not have the ability to procure them directly or adjust quantities based on patient needs. If they do have direct access to funds, there may be strict regulations about use of those funds and little flexibility in their allocation. Clinical staff might lack training in financial management, and the information infrastructure necessary for good accounting may be limited.

In addition to public funds, internally generated funds – including user fees and other revenues collected directly by facilities – may constitute a pool of discretionary funds at the facility. In some contexts, internally generated funds are controlled by facilities, while in others, facilities are required to return them to the district or central treasury. If controlled by facilities, these funds are sometimes “off-budget” (not included in the official budget) and have weak or absent reporting requirements. ¹ In many contexts, different sources of funding are intended for different portions of the facility budget, but facilities often have difficulties managing and accounting for these fragmented funds.

Increasing facilities’ autonomy to manage funds

“Provider autonomy” refers to the extent to which frontline facility managers have the authority to function as funds managers and to change the mix of inputs and services they provide based on their patients’ needs (e.g. to respond to an unexpected outbreak of disease or to adapt to a change in drug pricing). When health facilities have strong financial management capacity and authority to make some financial management decisions, they are more likely to adjust service provision and deploy inputs based on the needs of the population. ² 

Introducing greater provider autonomy in funds management at the facility level typically requires reforms to a country’s Public financial managementThe rules and regulations established to ensure transparent, effective, accountable management of public (government) finances. PFM includes all phases of the budget cycle, including the preparation of the budget, budget execution, internal control and audit, procurement, monitoring and reporting arrangements, and external audit. (PFM) regulations. ⁶ PFM regulations aim to promote transparent, effective, accountable management of government finances. ¹ They touch upon all phases of the budget cycle, including the preparation of the budget, internal control and audit, procurement, monitoring and reporting arrangements, and external audit. However, some PFM rules – intended to ensure predictability of spending and careful fiscal control -- can create inefficiencies in the health sector, where health care needs are unpredictable and quick responses to crises are essential.  

Changes to PFM regulations may be needed to increase the authority of lower-level spending units (including health facilities) to flexibly move funds across budget lines. This can improve PHC performance by enabling facilities to respond to changes in population needs and provider payment incentives more nimbly. ¹ (In general, these changes should be integrated into broader health system reforms ⁷, including but not limited to primary care, and must be closely coordinated by the Ministry of Finance.)

Budget officials may consider disbursing some cash income directly to primary care facilities, rather than only in-kind inputs.  This can provide facility managers more flexibility to reallocate funds as needed. Recognizing that most medicines and supplies will be bulk-procured centrally, allowing facilities to procure small amounts of medicines and supplies with their funds may reduce both wastage and stock-outs and improve responsiveness to short-term local needs. Dedicated facility bank accounts are necessary for facilities to receive direct funds transfers, and allowing them to receive cash income and open bank accounts may require changing their legal status; this can be a serious bottleneck in some contexts. Facility bank accounts can also help expedite disbursements and increase budget execution rates. 

Ensuring alignment between how facilities receive funds and Public financial managementThe rules and regulations established to ensure transparent, effective, accountable management of public (government) finances. PFM includes all phases of the budget cycle, including the preparation of the budget, budget execution, internal control and audit, procurement, monitoring and reporting arrangements, and external audit.  regulations on how funds are used and accounted for is critically important. In many countries, the beneficial impacts of provider payment reforms (see the Health Financing improvement strategy) have been muted by a lack of provider autonomy to allocate funds at the facility level, sometimes due to strict PFM rules. At the primary level, greater provider autonomy has been most commonly introduced through Performance-based financingProviding financial incentives to providers based on the achievement of pre-defined, measurable, and agreed-upon performance targets. or results-based financing programs (e.g. Zambia, Rwanda, Nigeria, Democratic Republic of the Congo, Burundi). ⁸ Similar “Direct facility financingThe practice of directly transferring funds to health facilities for their management and use. ” interventions, where cash funds are directly transferred to primary care facilities and they are granted autonomy in the planning, management, and use of those funds to improve service delivery, are underway in Kenya ⁹ and Tanzania. ¹⁰ 

Strengthening financial management capacity

Of course, facilities with increased autonomy to manage some of their own funds still require overall guidance on how funds can be utilized, with monitoring to ensure appropriate use and prevent leakage. In order to effectively manage facility budgets, managers must have the capacity to engage in proactive planning and forecasting, and to account for and report on expenditures incurred at the facility level.  Health system leaders should provide training and financial management guidelines to support facility managers in the forecasting and reporting processes. At the primary care level, training in management of a cash book can support day-to-day expenditure management, while larger facilities often require dedicated accounting and/or financial management staff. ⁶ In larger facilities, managers should have the capacity to develop and negotiate facility business plans to guide spending. Adequate financial management information systems are essential to track expenditures and report on cash income.

In addition to training, under systems with increased provider autonomy health system managers must also employ new or strengthened accountability systems to ensure that facilities are utilizing funds for their intended purpose. ^{6 9}  Improved recordkeeping at the facility level can increase the accuracy of public expenditure tracking surveys, which can be utilized to monitor improvements in funding flows to facilities over time.
 

Budget: A document that outlines forecasted revenue and planned expenditure for an entity (government, subnational unit, or health facility) over a defined period of time. Budgets indicate how funds are meant to be allocated to achieve certain objectives. 

Financial management: Systems and processes at the facility level to track revenues and expenditures, ensure that resources are not wasted, and ensure that desired results are achieved

Public financial management (PFM): The rules and regulations established to ensure transparent, effective, accountable management of public (government) finances. PFM includes all phases of the budget cycle, including the preparation of the budget, budget execution, internal control and audit, procurement, monitoring and reporting arrangements, and external audit. 

Program-based budgeting (also known as output-based budgeting): Developing budgets based on the resources needed to achieve program objectives (or produce desired outputs or results).

Performance-based financing: Providing financial incentives to providers based on the achievement of pre-defined, measurable, and agreed-upon performance targets.

Direct facility financing: The practice of directly transferring funds to health facilities for their management and use.  

Top-down budgeting: Budgeting process in which a central (national) authority determines resource allocations based on revenues available.

Bottom-up budgeting: Budgeting process in which health facilities or other subnational units estimate the budget needed to meet local service delivery needs.