Main Evaluation Conclusions
5. Monitoring and Evaluation: An overall framework for monitoring and evaluation is lacking and the roles and inter-relationships between Health Management Information,
9.3 The Pattern of Spending in Health Overview
With regard to the share of health sector actual expenditure by administrative level, it is possible to track the relative share of on-budget financial resources accounted for by MOHSW, PMO-RALG, the Regions and Local Government Authorities.55
The share of MOHSW (which also includes its expenditures on regional hospitals) has risen steadily over the evaluation period from a 57% share in FY 2001 to 62% in FY 2006. Councils have seen their share decline from 36% to 32% in the same period but have maintained their strong second place in the hierarchy. At the same time, PMO- RALG achieved an increase in its share of total expenditures from a very low base at the beginning of the period to 10% in 2006, as it took over responsibility for use of the HBF component for emergency rehabilitation of health facilities.
The overall pattern is one wherein the central level represented by MOHSW maintains and even slightly increases its share of expenditures while the Councils see a gradual but steady decline in their share which accelerates somewhat in the estimates for FY 2006,56 and
PMO-RALG sees significant growth in the same year (but some of the funds it receives are spent on rehabilitation of LGA facilities). Although their expenditure as a share of
55) On-budget health finances include allocations to Vote 52 for MOHSW, Vote 56 for PMO-RALG, Vote 23 for NHIF subventions, sub-votes 3001 (curative) and 3002 (preventive) for Regions, and allocations to sub-votes 5010-5013 for Councils.
0UIFS )VNBO3FTPVSDF%FQBSUNFOU 1SFWFOUJWF4FSWJDFT $IBSU.0)483FDVSSFOUBOE%FWFMPQNFOU&YQFOEJUVSFBT4IBSFPG5PUBM ':': 4IBSFPGUPUBM $VSBUJWF4FSWJDFT 1PMJDZBOE1MBOOJOH
total expenditure has decreased marginally, the volume of Council expenditure on health has increased in absolute terms in each year under evaluation. The volume of health related expenditure in FY 2005 at LGA level was more than four times higher than in FY 2000. Given the high priority assigned to strengthening district health services as a strategy in HSSP3, it is remarkably difficult to track the actual level of public health expenditures at district level (including both on and off budget expenditures and expenditures by
MOHSW). If funds allocated for expenditure at local level can be tracked and reported more effectively, it should be possible to establish targets for increasing the share of resources allocated to the LGAs for health.
By reviewing the share of recurrent spending accounted for by preventive services/pri- mary care, in comparison to the share for hospitals and for MOHSW administrative services, the evaluation was able to do some analysis of the functional allocation of on- budget health recurrent expenditures.
Since FY 2001 there has been a convergence of the share accounted for by hospitals and the share spent on preventive services/primary care with the former declining from 50% to under 45% and the latter rising from just over 40% to just over 45%. These changes over time may be indicative of a trend to increasingly favour PHFs and preventive care, but the evidence is far from convincing given the small size of the changes.
MOHSW
The evaluation examined the trend in MOHSW combined recurrent and development expenditures in five different categories (policy and planning, curative services, preven- tive services, the human resource department and “other”)57 using data from the
Ministry of Finance Integrated Financial Management System.
57) The category encompasses administration and general, finance and accounts, chemist lab agency, chief medical officer, TFDA and social welfare expenditures.
Perhaps the most important pattern in MOHSW spending has been the increasing share of preventive relative to curative services, especially since FY 2004, although both
increased in nominal terms. In contrast, the share of actual expenditure accounted for by policy and planning has decreased in both relative and nominal terms. Whereas roughly USD 13.2 million was spent in FY 2001, only USD 1.5 million was spent in FY 2006. The reason for this decline is not readily apparent in the accounts themselves.
Council Level Health Expenditures
Health is one of the largest cost centres for Councils, second only to education.58 The
share of total health finances going to the Councils has fluctuated quite significantly between a third and a quarter of total on-budget estimates for the evaluation period.59 In
absolute numbers there are indications that the HBF has played a key role in strengthen- ing district level health services. For example, a notable increase of 28% in on-budget health finances to councils was reported from FY 2004 to FY 2005; the year in which the health basket increased significantly. The CCHPs of the Councils subject to district case studies can be analysed with a view to obtaining a rough estimate of the breakdown of council-level health expenditure.60 In FY 2006 29% of total Council health spending
went to the Health Department, increasing from a level of 25% in FY 2000. The share going to dispensary costs on the other hand has decreased from 45% in FY 2000 to 27% in FY 2006. Finally, the share going to rural health centres has decreased from 27% in FY 2000 to 16% in FY 2006.
A clearly positive development has been the use of more transparent and fair criteria for allocation of the HBF and block grants introduced in the course of the period under evaluation. The new formula approved by the BFC in October 2003 has been applied to components of block grants since July 2004. This has strengthened the equitable alloca- tion of resources to the health sector and generally favoured rural councils, although the “hold harmless” principle continues to distort the picture somewhat since no council is permitted to experience a decline in resources as a result of the application of the for- mula. On the other hand, the Personal Emoluments (PE) component of the Block Grant is yet to be based on a similar type of allocation formula.61 According to data from the
FY 2005 PER, roughly two-thirds of health related intergovernmental transfers were going to the PE component. The need for a more transparent allocation mechanism for this component seems clear.
58) There are four sub-votes at the local government level, dealing with health expenditure: curatives services, preventive services, health centres, and dispensaries and clinics.
59) The Councils’ FY was January-December until June 2004 after which it was harmonised to run from July to June in accordance with the FY of the central Government.
60) No aggregated data is available.
61) Recurrent public expenditures in Tanzania are commonly broken down into wages and wage-related expenditures such as pension and NSSF contributions (Personal Emoluments, or PE) and non-wage expenditure (Other Charges, or OC). Source: logintanzania.net and MoF Budget Preparation Guidelines, Forms for Budget Submission and Implementation.