Tracking health expenditures in Papua New Guinea

Colin Wiltshire

Overview

1. Present findings from a health expenditure tracking and facility survey in PNG

2. Provide a snapshot of how health clinics receive funding to meet costs for delivering basic services

3. Implications of the financing system for service provision and operational activities conducted at clinics

4. Politics of expenditure reforms in PNG’s health sector:– Free primary health care subsidy payments to clinics

– Political driven health development expenditures

3

Promoting Effective Public Expenditure (PEPE) Project• Joint partnership between PNG’s National Research Institute and Devpolicy Centre at ANU

1 – Analyse priority expenditures in the national budget2 – Research into how expenditure reforms are implemented

• PNG has experienced a minerals boom leading to increasing public expenditure.

• More evidence is needed to understand if this spending is making a difference.

0

20

40

60

80

100

120

140

160

180

200

220

2002 2006 2010 2012

Health Education

Per capita government spending on health and education, 2011 kina

0

10

20

30

40

50

60

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

197

7

197

9

198

1

198

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198

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3e

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5p

201

7p

Kin

a b

illio

n

Kin

a

GDP per capita (lhs) GDP (rhs)

GDP and GDP per capita, 2012 prices

Tracking funds to health facilities

• Builds on 2002 Public Expenditure and Service Delivery (PESD) Survey

• Attempted to visit the same primary schools and health facilities a decade later

• Eight provinces representing four regions of PNG:

– Southern region (Gulf, National Capital District)

– Highlands region (Enga, Eastern Highlands)

– Momase region (Sandaun, Morobe)

– Islands region (West New Britain, East New Britain)

• Random selection of districts, primary schools, health facilities

4

• Five health survey instruments – Officer in Charge, another health worker, user, district and provincial health managers.

• Tracked health reforms, including health function grant, which funds essential operational activities at the facility level.

5

0

9.111.8 11.5 13.4 14.5

28.4

39.2

51.3

64.4

73.8

89.4

K0

K10

K20

K30

K40

K50

K60

K70

K80

K90

K100

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Increasesinhealthfunc ongrant:2003-2014(kinamillions)

Primary health care facilities visited

142 health clinics visited:

• 60% Government-run

• 37% Church-run

• 3% Private-run

Gender of OIC:

• 2002 - 34% female

• 2012 - 43% female

Other health workers:

• 2012 - 62% female

6

ProvincialReferralHospitals Nonesurveyed

RuralHospital/DistrictHealthCentre 9visited(6%ofsample)

HealthCentre

SubHealthCentre

AidPost

AidPost

AidPost

Urban/RuralClinic

32visited(23%ofsample)

44visited(31%ofsample)

57visited(40%ofsample)

Health facility financing results

Three main ways clinics get funding/support to deliver services:

1. Cash funding through budgets or direct payment

2. in-kind support: administered to health facilities

3. Charging fees for services.

Funding received through budgets

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34%

25%

19%

12%

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30%

40%

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70%

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100%

Budget prepared Budget submitted Budget approved Funding received

• 41% of health centres prepared a budgets

• 25% of aid post prepared budgets

Average value of budgets submitted & received

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63,771

45,467

107,500

31,645

9,567

77,254

K 0

K 20,000

K 40,000

K 60,000

K 80,000

K 100,000

K 120,000

All State Church

Budget Submitted

Budget Received

• 6% of clinics received direct funding (K71,000)

• Medical equipment was the most common purchased goods

• Estimated value of items: Church - K78,600 ; State K20,200

10

In-kind support administered to clinics from funding providers

11

Clinic decision making and satisfaction with support received

12

1.62

23.525.7

15.7

K0

K5

K10

K15

K20

K25

K30

General consultation Domestic violence Tribal fights Births

Fees: Clinics charge different fees for different services

• 83% of clinics charged for consultations or drugs

Huge variations in monthly user fees raised…

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1020

59

484

751

209

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1800

ENB ENGA WNB MOROBE EHP NCD SANDAUN GULF

All

HC+

Aid Post

Avg All

Avg HC+

Avg AP

• There is some disagreement between the OIC and the community about refusing treatment for those who cannot afford to pay.

39%

33%

18%

0%

11%

35%

26%

10%

18%

10%

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5%

10%

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25%

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35%

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45%

50%

fee is exempted allowed to pay according toability

allowed to pay in kind unable to recieve treatment something else happens

What happens when a patient cannot afford the user fee? Officer in Charge and user perspectives

OIC

User

55%

67%

79%

75%

50%

69%

91%

79%

69%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ENB WNB MOROBE SANDAUN EHP ENGA GULF NCD

Community perceptions of user fees at the health facility

TOO LOW

ABOUT RIGHT

TOO HIGH

AVERAGE

Relative importance of these three funding sources

16

17

11%

31%

11%

5%

12% 12%

27%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Own budget In kind User fees Own salary Other Referral healthclinic

Do not provide

Clinics meet expenses for conducting outreach patrols through...

18

PNG’s health financing system

• The health financing system does not provide reliable funding to clinics

• Majority do not receive cash funding to meet expenses for their operations and therefore need to collect fees or rely on in-kind support

• The health function grant is not commonly used to fund budgets, but is kept at the provincial and district health office and provided in-kind

• Important differences exist between church and government-run clinics when it comes to financing

• Model of direct facility financing in Bougainville, facility budgeting and funding LLG health managers in East New Britain

• Given these circumstances, policy should be focused on improving the effectiveness of current reforms, but is it?

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PNG’s free primary health care policy

• Launched on 24 February, 2014

• Key policy for the PNG Government set out in the AllotauAccord and politically driven

• K11m subsidy payments allocated to offset fees raised by health clinics

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Challenges with implementing the policy

How will subsidy payments be allocated across provinces:• An even allocation will result in some provinces getting too much, while

others won’t get enough

• User fees previously raised can not be taken into account

• Needs basis could be considered using NEFC cost of service estimates but also has flaws

How will subsidy payments for the policy be distributed?• The costs associated with distribution need to be taken into account.

• Each province faces its own challenges in accessing reliable financial services, such as banks.

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Getting subsidy payments to health workers

• Should funds be placed into health facility bank accounts?– Only 44% of health facilities have bank accounts

– OIC’s accessing their own funds can be expensive and inefficient

22

847.5

727.1

496.2455.8

253.5

62.319.8 2.3

365.8

0

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SANDAUN WNB MOROBE GULF ENB EHP ENGA NCD

Cost in kina to collect pay and return to post: All expenses

All

HC Plus

Aid Post

Average

23

The rise of constituency funding in PNG (Kina million)

20 per cent of K1.5 billion (K350 million) has been allocated for health capital spending

Politically driven health expenditures: Services Improvement Program (SIP)

Spending though politicians in PNG is high by international standards

0%

2%

4%

6%

8%

10%

12%

Ratio of constituency funding to total spending (%)

24

(Howes & Sofe 2014, PNG Budget Forum)

Was DSIP funding spent effectively? Perspectives of health facilities and schools

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Responsibilities for SIP implementation

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DistrictAdministrator

Health

Centre

DistWorks

DistEdu

DistrictHealth

Manager

JDP/BPC:

Joint District

Planning / Budget

Priority Committee

MEMBERSHIP:

- Open MP - Chairman- LLG Presidents x LLGs- Other Reps – woman,

church, youth/community

Administers,

monitors and

reports on

implementation

Allocates DSIP

projects for

implementation

Reports back on

DSIP projects

Aid

Post

Aid

Post

Health staff

Health staff

Health staff