Factors that contribute to high health budget execution ABC · 9/1/2017 · Comparison to Bihar & Uttar Pradesh 5 6 ... - PEFA 2016 Framework - Budget, expenditure analysis - Qualitative

ABCFactorsthatcontributetohighhealthbudgetexecutionDeepDivesinKerala,MaharashtraandRajasthan,INDIA

2017

Context,RTMframework1

Keyquestions,approach,frameworkforthedeepdive2

Fiscalattributes,healthfinancingattributes3

Currentpractices:Lookingforanswerstokeyquestions4

Examplesofcurrentpracticesyieldingbetterresults

ComparisontoBihar&UttarPradesh

5

6

Whatfollows…

Conclusionandrecommendations7



Fiscalattributes,healthfinancingattributes3




5

6

Whatfollows…


TheResourceTrackingandManagementConceptualFramework

ResourceMobilization

Whatisthepotentialforraisingmoreresourcesforhealth?Fromwhere?Whatdeterminestheresourceenvelopeatnationalandsub-nationallevels?

ResourceAllocation

Howarefundsallocatedtodifferentprogramsandfunctionsatnationalandsub-nationallevels?Whatfactorsdeterminetheallocationtoprimarycare?

ResourceUtilization

Aretheallocatedfundsbeingutilized?Whatfactorsdrivesuccessfulbudgetexecution?Whataretheexistingbottlenecks?

ResourceProductivity

Howeffectivelyareresourcesbeingtranslatedintoservices?Isdeliveryefficientandwhatcanbegainedfromefficiencyimprovementsintermsofvolumeandquality?

ResourceTargeting

Areinputsbenefitingtheintendedindividualsandpopulation?Ispublicspendingreachingthepoor?



Fiscalattributes,Healthfinancingattributes3




5

6

Whatfollows…


BackgroundoftheRTMstudy

- 2008-09to2014-15- Sources,allocations,utilization

Nationalstudy

Primarycare

Deepdive:Bihar

Deepdive:UP

- 29states;2005-06to2013-14- Central&statesourcesof

funding

- 16states;2005-06to2013-14- Detailedanalysisofprimarycare

budget&expenditure- 2007-08to2013-14- Sources,allocations,utilization

- UP&Biharshowsignificantunderutilizationoffundsavailableforhealth,particularlyNHM

- Underutilizationofscarcehealthresourcesfurtherdiminisheshealthexpenditurelevels.

- Stateswithlowexpenditurelevelsalsosufferfromweakbudgetexecutioncapacity.

Leadingtothekeyquestion…Whatarethefactorsthatenableorinhibitstatesfromutilizingavailablefunds?

Emergingconcerns

Deepdives:3states- 2012-13to2014-15- Kerala,Maharashtra&Rajasthan- Factorscontributingtohighbudgetutilization

Keyquestionsforthedeepdive…

PerformanceofKerala,MaharashtraandRajasthan

Budgetexecution

What policyfactorsenablebetterbudgetexecution?

Policyfactors

Whatoperational/processfactorsfacilitatebetterexecution?

Operational/processfactors

Whatleadershiptraitsorgovernancefactorsenablebetterexecution?

Leadership&governance factors

Specificallywhattypeofcapacitiesarebetterandatwhatlevelsthatfacilitatebetterexecution?

Human capacityfactors

2012-13to2014-15

- PEFA2016Framework- Budget,expenditureanalysis- Qualitativeinterviews

Understandingreasonsforbetterutilizationoffunds

Treasury&NHM

Ernakulum&Kozhikode:KeralaPune&Nagpur:Maharashtra

SriGanganagr&Tonk:Rajasthan

Approachforthedeepdive

Consistentlyhighutilizationrates(underthetreasury&NHMroutes)

Rajasthan

Conveniencesampling:Stateswereselectedbasedontheirpopulationandgeographicalattributesinadditiontotheir(high)budgetutilizationratesDistrictswerechoseninconsultationwiththestateofficials

PublicExpenditureandFinancialAccountability(PEFA)Framework2016indicatorswereadaptedtodevelopachecklistforqualitativeinterviews.PEFAisrestrictiveandexaminesonlyfromaPFMperspective,theauthorshadtoadapttheframeworktocapturespecificnuancesofthehealthsystem.

Responsebias(governmentofficials)

Processesweredocumentedbasedonresponsesreceivedfromstate&districtofficials.Thisstudydoesnotfocusontheeffectivenessofprocessesdocumented.

Limitations

Limitations

Frameworkforthedeepdive

- Aggregateexpenditureoutturn

- Auditcoverage- Timeliness- Actiontakenon auditreports

- Predictability ofin-yearresourceallocation- Procurement- Payrollcontrol- Internalcontrolonnon-salaryexpenditureIndicatornotused

- Budgetclassification- Allocatingtransfers- Timelinessoftransfers- Performanceevaluation

- Mediumtermexp. estimate- Mediumtermexp.ceiling- Alignment ofplan&budget- Budgetpreparationprocess

- Financialdataintegrity- Financialreports

AdaptedthePEFA2016Framework(PublicExpenditureandFinancialAccountabilityFramework,2016)

Context, RTM Framework1

Key questions, approach, framework for the deep dive2

Fiscal attributes, health financing attributes3

Current practices: Looking for answers to key questions4

Examples of current practices yielding better results

Comparison to Bihar & Uttar Pradesh

5

6

Whatfollows…

Recommendations7

Fiscalattributes:Inter-statecomparison

MaharashtraRs130,525

KeralaRs113,114

RajasthanRs74,008

UttarPradeshRs41,530

BiharRs34,267

01 Kerala8.07%

02 UttarPradesh7.72%

Maharashtra7.19%

04 Rajasthan6.47%

05 Bihar5.81%

01 Bihar3.7times

Rajasthan3.2times

03 Maharashtra2.8times

04 Kerala2.7times

05 UttarPradesh2.5times

PerCapitaIncome:2013-14

State’sOwnTaxtoGSDPratio:2013-14

PerCapitaIncomeGrowth:2005-06to2013-14

01

02

03

04

05

Fiscalattributes:Inter-statecomparison

- Despitehigheconomicgrowthrate,Biharappearstobemostdependentoncentralsupport(69%oftotalrevenuereceipt).

- Maharashtra– leastdependent(20%)

Central support dependency (2013-14)as a share of total revenue receipt

51%

15% 11% 25%

37%

18%

8% 9%

12%

13%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Bihar Kerala Maharashtra Rajasthan UttarPradesh

ShareinCentraltaxes CentralGrants

Healthfinancingattributes:Inter-statecomparison

- Bihar:onlystate,amongthe5studied,withshareofhealthspendingdecliningin7years.

- InricherstateslikeKeralaandMaharashtrathegovt.spendslessthan1%ofitsGDPonhealth

- UP:Nochangebetween2005-6&2013-14;thoughitpeakedat1.39%in2006-07

Total Government Health Expenditure (TGHE) as a share of GSDP:Comparing 2013-14 with 2005-06 levels

1.34%

0.74%

0.47%

0.88%

1.13% 0.99% 0.99%

0.55%

1.06% 1.13%


2005-06 2013-14


- Bihar&UP:TGHEasashareoftotalstateexpenditurehasdeclinedin7years.

- Kerala,MaharashtraandRajasthan:SignificantincreaseinTGHEshare

TGHE as a share of Total State Government Expenditure:Comparing 2013-14 with 2005-06 levels

5.11% 5.20%

3.49%

4.80%

6.20%

4.40%

6.42%

4.73%

6.14% 5.34%


2005-06 2013-14


KERALA (Rs 1122)01

RAJASTHAN (Rs 788)02

MAHARASHTRA (Rs 714)03

UTTAR PRADESH (Rs 461)04

BIHAR (Rs 339)05Real: Rs 200

Real growth: 75%

Real: Rs 248Real Growth: 42%

Real: 424Real Growth: 99%

Real: 392Real Growth: 99%

Real: Rs 641Real growth: 117% TGHE per capita

Nominal (2013-14) & Real (@ 2004-05 prices) Real growth from 2004-05 to 2013-14

Healthfinancingattributes:Inter-statecomparisonTGHE per capita growth rateBetween 2005-06 and 2013-14

175%

264%

224%

283%

149%

50%

117% 99% 99%

42%


Nominal Real

Rajasthan,KeralaandMaharashtraexperiencedasignificantlyhighergrowthrateinTGHEinthelasteightyearsbothinnominalandrealterms.

- OverallgrowthoffinancingthroughNHMissignificantlyhigherthanthetreasuryroutefinancing.

- UP andMaharashtraregisteradeclineinNHMfinancingin2013-14(overthepreviousyear).

Treasury & NHM financing growth rates (nominal)

154% 264% 233%

295% 193%

720%

556% 685%

624%

444%


Healthexpendituregrowthratebetween2005-06and2013-14

Treasury NHM

7%

12% 15%

22%

7%

13%

7%

-2%

23%

-7%


Growthratebetween2012-13and2013-14

Treasury NHM


GPHCE as a share of TGHE

0%

10%

20%

30%

40%

50%

60%

70%

80%

2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14


- DespitethehighproportionofGovt.PrimaryHealthCareExp.(GPHCE)asashareofTGHE,inabsolutetermstheamountsareverymeagerforaqualityprimarycarepackage.

- AsashareofTGHEKeralaisconsistentlythelowest. Butpercapitaprimarycareexpenditureisthehighest.

2013-14 Bihar Kerala Maharashtra Rajasthan UttarPradesh

ShareofTGHE 65% 38% 56% 61% 58%

Percapita GPHCE Rs222 Rs431 Rs360 Rs480 Rs274


…fromfiscalandhealthfinancingattributesofthe3statesweobserve...

• Highpercapitaincomeandlowerdependencyoncentralsupport.

• Highpercapitagovernmenthealthexpenditureonhealth.

• Highlevelsofexpenditureonhealthisnecessarybutnotadequateconditionforhealthoutcomes.

• Factorslikequalityofimplementation,effectivenessofinvestments,andleadershipplayasignificantroleinimprovinghealthoutcomes.

…healthoutcomes

StatesInstitutionalDelivery* Immunization* MMR^

2005-06 2015-16 2005-06 2015-16 2004-06 2011-13

India 38.7 67.5 43.5 62 254 167

Bihar 19.9 63.8 32.8 61.7 312 208

Kerala 99.3 99.9 75.3 82.1 95 61

Maharashtra 64.6 90.3 58.8 56.3 130 68

Rajasthan 29.6 84 26.5 54.8 388 244

UttarPradesh 20.6 67.8 23 51.1 440 285

Source:*NFHS&^SRS

74% 43% 34%

221%

88%

33% 1% 9%

36% 40% 4%

48%

184%

107%

37%

229%

122%

35%

IncreaseinInstitutionalDelivery(between2005-06&

2015-16)

IncreaseinImmunization(between2005-06&2015-16)

ReductioninMMR(between2004-06&2011-13)

Changeinkeyindicatorsovertime

India Bihar Kerala Maharashtra Rajasthan UttarPradesh

Context, RTM framework1


Fiscal Attributes, Health Financing Attributes3




5

6

Whatfollows…

Conclusion & recommendations7



Budgetexecution

Whatpolicyfactorsenablebetterexecution?

Policyfactors







BudgetExecution

- Averagebudgetutilizationof>90%forallstates,exceptBihar.

- Bihar:decliningtrend:71%in2013-14

Budget utilization (Treasury route)

82%

95% 94% 95% 90%

0%

20%

40%

60%

80%

100%

120%


2005-06 2006-07 2007-08 2008-09 2009-10

2010-11 2011-12 2012-13 2013-14 StateAverage

- Kerala,MaharashtraandRajasthanutilizeNHMbudgetinitsentirety.

- BiharandUPsufferfromarangeofissuesthataffectbudgetutilization– primarilyattheStateHealthSocieties

NHM utilization

67%

110%94%

75% 77%76%

113%98%

82% 84%

106%

77%91%

98%


AgainstapprovedNHMbudget

2012-13 2013-14 2014-15

41%

97% 99% 106%78%

50%

143%

95% 87%

47%

99% 98% 95%

61%


AgainsttotalavailableNHMfunds(includingopeningbalance&interestearned)

2012-13 2013-14 2014-15

BudgetExecution



Budgetexecution

What policyfactorsenablebetterexecution?

Policyfactors







Policyfactors• Existenceofpolicyframeworks– cleararticulationand

alignmentsofgoalsenablesfocusedplanning,realisticbudgetingandthereforebetterutilization.

• Politicalpriorityforhealth:50%ofallOTCA(OneTimeCentralAssistance)proposalsinKeralaarefromthehealthsector.

• Focusonsocialdeterminantsofhealth• PrioritytoMissionFlexiPool• Convergence:PRI– communityengagement

Someexamplesoflegislations&policies:- HealthPolicy2013(Kerala)– embeddedinSDGs- KeralaPublicProcurementAct,2014- KeralaPalliativeCarePolicy2008:everydistricthasaDistrictPalliativeCareCoordinator– GramPanchayatscontract

CommunityPalliativeCareNurses(trainedinpalliativecarefor3months).- RajasthanTransparencyinPublicProcurementAct,2012- MaharashtraStateDrugPolicy- Transferandpostingpolicies(Maharashtra)

- Thesefactorsleadtoneed-basedandrealistichealthplans.

- Appropriateinstitutionalandlegalframeworkimplementationandaccountability.

- Thereforeincreaseseffectivenessofinvestments.



Budgetexecution


Policyfactors







- Planning&budgeting- Fundflow- Monitoring- Procurement- Civilworks- Humanresource

Operationalfactors:Planning&budgeting(NHM)• Strongplanningcapacityatall

levels,includingatthePHCandbelow(VHSNC).

• Predeterminedunitcostsofmostbudgetlines.

• GapsduetoresourceconstraintsinthestatebudgetfeedintotheNHMplanning.

• ActiveengagementofRogiKalyanSamities(HospitalCommittees)

• Stronglocalleadership(district&blocks)

At all levelsState

DistrictBlockPHC

GoI to StateState to Districts

Districts to Blocks

IntensiveSupport and

frequent Follow ups

At all levelsStrong PRI

leadership and engagement

PHC LevelBlock level

District levelState level

NegotiationsApprovals

01 02 03 04 05 06

Guidelines PlanningMeetings

Mentoring PRI engagement

Review&

Conso-lidate

Review&

Approvals

CRITICALSUCCESSFACTORSInKerala,RajasthanandMaharashtra

Greateranalyticalcapacityobservedatthedistrictleveltomakerealisticplansandbudgets.

OperationalFactors:Planning&Budgeting(NHM)Factorsthatcausedelayedapproval:

• DelayedsubmissionofPIPsbystates• QualityofPIPandbudget– timerequired

fornegotiations/revisions

Ø 2012-13:nomajordifferencebetweenstates

Ø Thereafter,significantdelaysinUP&BiharascomparedtoKerala.

Ø Maharashtra&RajasthanarenotmajorlydifferentfromBihar&UP.

Note:Delaysin2014-15wereanaberrationduetonationalelectionheldinAprilandMay2014

0%

10%

20%

30%

40%

50%

60%

Kerala Maharashtra Rajasthan Bihar UttarPradesh

Implem

entatio

ntim

eelapsed

DelaysinNHMPIPApproval

2012-13 2013-14 2014-15 2015-16 2016-17

no.ofdaysbetweenstartoffinancialyearandthedateofplanapproval

365days

Implementationtimeelapsed =

OperationalFactors:Planning&Budgeting(Treasury)

01K E R A L A

- TemplatesforPlanproposals- HospitalCommitteesundertakesituationassessmentsofsocialdeterminantsofhealthanddrawa

VillageHealthMapanddesignspecificprojectsbasedonspecificissues.- 2DepartmentWorkingGroupsforbudgetapprovalandnegotiation.UptoRs.5Croreschairedby

ACSHealth&aboveRs.5Crores,chairedbyACSFinance

02MAH A R A S H T R A

- Stateofficialsvisitselecteddistrictstoholdconsultationmeetingsforinputs.- Needsemergingfrommonthlyandquarterlyreviewmeetingsareinventorised.- DeputyDirector’sofficeattheCircleLevel(statedividedinto8administrativecirclesfor

administrationofthefunctionsofthehealthdepartment)provideclosersupport- LiaisonofficerdedicatedtomanagetherelationshipwithCenter,forpromptaction/followup

03R A J A S T H A N

- SeparateBudgetFinanceCommittees(BFC)forPlanandNon-Planbudgetreview.- BFCforPlanhasanadditionalmemberfromthePlanningDepartment.

- Stronginstitutionalstructures&mechanisms

- BudgetpreparationinstructionsissuedbytheDept.ofFinance

- Strongfamiliaritywiththeguidelinesarelowerlevels

- ExtensiveuseofITapplicationsandsoftwareformanagingallocationsinall3states.

- Maharashtra:BEAMS(BudgetEstimation,AllocationandMonitoringSystem)–forauthorizingexpenditureandmonitoring.

OperationalFactors:Planning&Budgeting(Treasury)

Maharashtra,Kerala,andRajasthanhavehighbudgetcredibilitycalculatedbyadaptingtherelevantPEFA2016indicators

4.003.67

3.33

- 0.501.001.502.002.503.003.504.004.50

ExpenditureOut-turn:Average3-year(2011-12to2013-14)aggregatescore

ExpenditureOut-turn=Expenditure(Actuals)asashareofBudgetEstimate



Budgetexecution


Policyfactors








- All3studystateshaveensureduniformavailabilityoffundstodistrictsacrossallquartersexceptKeralain2012-13.

- KeralaNHMborrowsfundsfromthestatepooltoensureuninterruptedfundsfordistricts

Prompt availability of NHM funds to districts ensures timely utilization.

OperationalFactors:Fundflowdecisionsandtimeliness

- TimelyreleaseofStateshareinKerala&Rajasthan

- Maharashtra:delaysinreleaseofstateshare;butbettersystemtoexpediteimplementation

17% 17% 15% 19%

48%

11% 18% 23% 22%

20% 42%

33% 42%

0%

8%

25% 37%

26% 0%

16% 31% 20%

21%

28%

27% 15%

24% 63%

25% 21% 19% 31%

54% 30% 25% 27%

0%

20%

40%

60%

80%

100%

120%

2012-13 2013-14 2014-15 2012-13 2013-14 2014-15 2012-13 2013-14 2014-15

Kerala Maharashtra Rajasthan

QuarterwisesharesofNHMfundtransferfromstatetodistricts

Quarter1 Quarter2 Quarter3 Quarter4

- Kerala,Maharashtra&RajasthantransfermostoftheMFPfundstodistrictsbeforethestartofquarter1(exceptKeralain2012-13andMaharashtrain2014-15)

Mission Flexi Pool is prioritized in 3 states unlike UP and Bihar.

OperationalFactors:Fundflowdecisionsandtimeliness

0% 10% 20% 30% 40%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42012-13

2013-14

2014-15

RAJASTHAN:NHMfundtransfertodistricts

ShareofTotalTransfers ShareofMFPTransfers

0% 20% 40% 60% 80%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42012-13

2013-14

2014-15

KERALA:NHMfundtransfertodistricts


0% 20% 40%

60%

80%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q42012-13

2013-14

2014-15

MAHARASHTRA:NHMfundtransfertodistricts


Rajasthan:includingInfrastructure&Maintenance)I&MfundsKerala&Maharashtra:excludingI&Mfunds



Budgetexecution


Policyfactors








OperationalFactors: BudgetexecutionandmonitoringKERALA• Strongmonitoringsystemsensuringhighleveloftransparency.

• Focusontrackingresults,notexpenditure:monitoringvisitsfocusmoreontrackingresultsagainsttargets.

• E-monitoringthrough“PLANSPACE-Kerala”,aweb-basedinformationsystemforconcurrentmonitoringandevaluationofPlanSchemes.Expenditurestatementsaresentmonthly/quarterlyfromDrawingandDisbursingOfficertofinanceunit.Reconciliationisdoneonceaquarter.

• BudgetAllocationMonitoringSystem(BAMS)isusedbothbyHealthandFinancedepartmentstomonitorbudgets.Programreviewsfollowaschedule– typically– betweenAugustandDecember,oncein2months.Jan– Marchoncein2weeks.

• ACentralPlanMonitoringUnitisestablishedatDeptofFinancetooverseeexpendituresfromeachdepartmentonamonthlybasis.

• Re-appropriationisnotcumbersomeparticularlyfornon-planexpenditures.

OperationalFactors: Budgetexecutionandmonitoring

KERALA

• StandingCommittees(electedrepresentatives)forHealthinGramPanchayats- veryactiveandstrong– WorkingCommitteeforhealthwithrepresentativesfromWards

• Strengtheningonehospitalineachdistrictwithsupportfromdecentralizedplan.MasterPlanswerepreparedandordersissuedtoKMSCLtoengagearchitectandhospitalconsultanttodevelopMasterPlanforeachhospital,costsofwhichwillbemetfromtheHospitalDevelopmentSociety/RSBY.

• Demandgenerationactivitiescreatepressureonthesupplysidetodeliverhighqualityservices(example,‘RadioHealth’projects– 2008:messagingaboutNRHMthroughFMandAMradio– forpromotinghealthliteracy;BrandingofNHMinKerala:Arogya Keralam Aishwarya Keralam)


KERALA

• Equipmentmaintenanceoutsourced

• Realtimeonlinemonitoring/tracking

OperationalFactors: BudgetexecutionandmonitoringMAHARASHTRA

• CommunitybasedmonitoringineachdistrictinvolvingNGOs(pictorialtoolsforcommunitymonitoring,publichearings,etc.)

• Extensiveuseoftechnology- videoconferencing,budgetplanningandmonitoring;payrolletc.

• GovernmentReceiptAccountingSystem(GRAS):https://gras.mahakosh.gov.in/echallan/ -:ensuresrealtimereconciliationandtrackingofavailablebudgets.Ithasreducedthetransactiontimefromabout10daystoapproximately1-2days.

• ExpenditureiscontrolledthroughreconciliationofpaymentslipsgeneratedbytheDDOswiththerecordsofanotherapplicationcalledtheTreasuryNet,managedbythePay&AccountsOffice.InternalapplicationusedonlybytheTreasury.

• Hightransparency– allsuchapplicationscontrolledbyDepartmentofFinance.


MAHARASHTRA:• SEVAARTH:https://sevaarth.mahakosh.gov.in/login.jsp ,anonlineplatformforpersonnel(including

personnelrecords)salaryandpensionmanagement.Payrollismanagedandtrackedthroughthisplatform.ThisislinkedtoBEAMS.

• ForServicebookverification:VETANIKAhttps://vetanika.mahakosh.gov.in/pay/ :linkedwithSEVARTH

• Finally,anotherapplicationKOSHWAHINIhttps://koshwahini.mahakosh.gov.in/kosh/kosh/ providesacompletefinancialMISwherereportsareavailable.Thesereportscanbeaccesseddepartmentwise,majorheadwise,districtwise,DDOwiseandagainstmanyotherparametersforanyspecifiedtimeperiod.

• WrittenmonthlyfeedbacktoallTalukasanddistrictlevelprogramofficersonphysicalandfinancialprogress.Specialmeetingscalledifutilizationisfoundtobelow.


MAHARASHTRA:

• BudgetutilizationandreallocationsaretrackedandeffectedthroughBEAMSinrealtime.Thesystemallowscomprehensiveandgranularexpenditureoverview.

• Intricatewebofthesee-applicationsareseamlesslyinterlinkedwitheachotherandprovidecomprehensiveinternalcontrolfortrackingexpenditure,reconciliationandduediligencepriortoreleaseofpayments.

• WeeklyvideoconferencingwithalldistrictCivilSurgeonsandDistrictHealthOfficersandotherofficials.

• GrievanceRedressalCommitteesetupatthestatelevelin2009forbeneficiariesandinternalstaff.Allgrievancesaretrackedandfolloweduptoconclusion.Departmenthasinitiatedinquiriesagainst29complaints.


MAHARASHTRA:

• Reviewmeetingswithalldistrictofficials:Monthlyinthefirstquarterandthenquarterly– intensivelineitemwisemonitoringofexpensesandutilizationlevels.

• DetailedreviewofexpenditurelevelsinFebruaryeachyear– fundsinobjectcodeswithlessutilizationaretransferredtothoseCodeswherefundsaremorelikelytobespent.

• SuchreappropriationswithinthesameSchemeandacrossSchemeswithinthesameMajor(Budget)CodecanbedonewithintheDepartment.


Maharashtra:MonitoringutilizationofVHSNCfunds

• Almost80%oftheVHSNCsorganizeregularmonthlymeetings.MeetingsaremonitoredbytheBlockDevelopmentOfficer/ChildDevelopmentProjectOfficerattheBlockLevelandtheDeputyCEOoftheGramPanchayat.

• BDOcallsformonthlyreviewmeetingsofallAanganwaadi Workers(AWW)undertheICDSprogram.SameplatformisusedforreviewingthefunctioningoftheVHSNCs– theDistrictASHA/RKScoordinatorsattendthesemeetings.TheTHO(TalukaHealthOfficer)alsoparticipateinsuchreviewmeetings.

• AWWtakestheVHSNC(VillageHealthSanitationandNutritionCommittees)expenditureregistertothePHCduringhermonthlymeetings.TheexpenditureregisterisreviewedandVHSNCexpenditurerecordsareenteredintothesystematthePHCforaggregationandfurtherupwardreporting.

• Thereareinstancesofcoordination/politicalproblemsbetweentheSarpanchandAWW(AWWshaveaUnioninMaharashtra).AllsuchissuesareresolvedthroughtheinterventionoftheCEOoftheZillaParishadandtheBDOwhereverrequired.

• MonthlymeetingsofdistrictRKSCoordinatorsaretrackedattheDistrictlevel.• Reportedlyabout70%oftheVHSNCssubmittheirmonthlyexpenditurereportsintime.


Maharashtra:MonitoringUtilizationofAMG/RKSFunds

• Regularmeetingsofthegoverningbody&executivecommitteeoftheHospitalcommittees

• ThesemeetingsaremonitoredbytheRKSCoordinatoratthedistrictlevelandalsobythestatelevelfunctionaries

• OfficialwrittenremindersaresenttotheRKSiffoundlagginginmeetingschedules.

• ExpenditureplanispreparedforeachRKSandapprovedbytheGBoftheRKS.

• AMGprovidedonlytothoseinstitutionswhichareingovernmentownedbuildings.

• UntiedfundexpenditureisanalyzedbasedonmonthlyexpenditurerecordsofeachRKS.FeedbackonexpenditureandutilizationtrendsisprovidedfromtheStatethroughwritteninstructiontotheRKSthroughappropriatechannels.

OperationalFactors: BudgetexecutionandmonitoringRAJASTHAN:• ExtensiveuseofITapplications

• Paymentplatformusedformonitoringperformance(ASHASoft)

• Useofvideoconferencingatalllevels

• Useofsocialmedia(Whatsappgroup):cadrespecificgroups– usedforsendingreminders,notifications,followups– hassignificantlyimprovedcompliancetoreportingdeadlines.

• Sectorapproachtomonitoring- geographicalresponsibilitiesassigned– monthlyfieldvisitplans

• Strongaccountabilitymeasures.Thereare(a)instancesofstafftransfers,suspensions,enquiriesasperRajasthanServiceRules;(b)writtenreminderoftheCEOoftheZillaParishad/DistrictMagistrateiftheDistrictHealthSocietymeetingsarenotheldintime, (c)stoppingofincrements,etc.


RAJASTHAN

• ITapplicationformonitoringimplementationofPre-ConceptionandPre-NatalDiagnosticTechniques(PCPNDT) Act

activetrackeronsonographymachines,GPSonnewmachines– separateCourtsforhearingofallcasesinalldistricts,regularinspections,allsonographycentersareregisteredonlinethroughtheIMPACTsoftware:launchedin2012

• PregnancyChildTrackingandHealthServicesManagementSystem(PCTS)

• ASHASoft:onlinesystemforcapturingbeneficiarywisedetailsofservicesgivenbyASHAs– onlinepaymentofASHAs,calculationofincentives,strengtheningmonitoringandmanagementofphysicalandfinancialprogress.

ResultedinconsistentpredictableincomeforASHAs– thathasfacilitatedasenseofsecurityandcommitment/motivation.


RAJASTHAN

• SaghanNirikshanAbhiyan(translation:IntensiveMonitoringMission):toidentifygapsinhealthservicesathealthinstitutions.Thisinitiativegivesaccesstoinformationanytimeandisusedformonitoringandplanning.Mobileappwheredatacanbeenteredduringthefieldassessment(inrealtime).

• E-upkaran:comprehensivesoftwareforinventorymanagementandmaintenanceservicesofequipment–thisallowsforcentralizedequipmentinventorymanagement,equipmentdetails(commissioning,decommissioning,vendordetails,AMC,etc.).Italsohasanequipmentcomplaintmoduleandequipmentusagemodule(updatedailyusage– totaltestsdonebytheequipment).Ensuresrationalizationofequipment/instruments/others,withinandbetweendistricts


RAJASTHAN

• Arogya OnlineProjectaninitiativetoautomatehospitalstoimprovethepatientcare - electronicmanagementofhealthinformationtodeliversafer,moreefficient,betterqualityhealthcare- facilitateselectronicclinicalrecordkeeping.

The‘Arogya Online’streamlineswork-flowoperations,resourceutilizationandmanagementtoimprovehospitaladministration,enhancesthequalityofpatientcare,createsplatformforinformationexchangeandendtoendsupplychainmanagement.


Budgetexecution

Whatpolicyfactors enablebetterexecution?

Policyfactors





Specificallywhattypeofcapacitiesarebetterandatwhatlevelbetterexecution?

InstitutionalandHuman capacityfactors



OperationalFactors: BudgetexecutionandmonitoringProcurementofmedicinesandmonitoringutilization

• KeralaMedicalServicesCorporation– KMSC(setupin2008)&RajasthanMedicalServicesCorporation– RMSC(setupin2011)

• CentralizedsystemforprocurementofdrugsandequipmentinKeralaandRajasthan.• StrongboardrepresentedbyseniormostofficialsintheDepartmentinbothKeralaandRajasthan.• Entiretenderingprocessisone-platform;inventorylevelsandsupplychainismonitoredonline• CompleteautonomytotheManagingDirectors.• KMSChassetupitsownrevenuegeneratingprojects– attimesduetoshortageoffundsfromthestatebudget,KMSCuses

itsownfundstopurchasetherequiredquantitiesofdrugsforthestateandseeksreimbursementfromthestatebudget.

States Averagetimeforprocurement (Medicines)

Averagetimeforprocurement(Equipment)

Kerala 120– 150days 75 days

Maharashtra 120– 180days 120– 180days

Rajasthan 120daysforfreshtender60days(ifRateContract)

120daysforfreshtender60days(ifRateContract)

DelayinsupplyofdrugsinBihar:- Madhubanidistrict:418days

- Gayadistrict:337daysAverageprocurementtimeinUP:

- Medicines:149days- Equipment:205days


Procurementofmedicinesandmonitoringutilization:KeralaResults

Inthelast9years:

• AllottedasashareofbudgetproposedbyKMSC:66%• Fundreleasedasashareofallottedamount:85%• Procuredasashareoffundsreleased:123%

72 64 58 58 57 59 59

82 8273100 100 100 100 100

68 75 71

132115 107 102

155127

149129

93

2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17

KMSCLFinancessinceinception(inpercentage)

Allottedasa%ofbudgetproposedFundsreleasedasa%ofbudgetallottedValueofdrugsprocuredasa%offundsreleased

§ Fundreleasedasashareofallottedamountreducinginrecentyears.

§ KMSChasplayedasignificantroleinensuringavailabilityofdrugsinthestate.


Procurementofmedicinesandmonitoringutilization:RajasthanResults

• ChiefMinister’sFreeMedicineScheme:freetoallwithoutanyidentification– enableseasyaccess– October2011

• SteepincreaseinpercapitaexpenditureonmedicinesinRajasthansincetheincorporationofRMSCL.

• Drugwarehouseateachdistrict.

• Empanelledlaboratoriesforqualitytestingofdrugs

• E-aushadhi forinventorymanagement

• Medicinesaresuppliedtothedistrictwarehouse– pooled&thetransportedtofacilities.

• ComputerizeddrugdispensinguptoPHClevel

• Transparentpaymentsystem

1612 11 13

6

15

30

49

2000-01 2006-07 2007-08 2008-09 2010-11 2011-12 2012-13 2013-14

PercapitapublicspendingonmedicinesinRajasthan(inRupees)

Source:http://www.searo.who.int/india/publications/rajasthan_report_2015_part4.pdf?ua=1

Drugs&TherapeuticCommittee– PrescriptionAudit(1%ofallOPD&IPDprescriptionsonamonthlybasis)


Budgetexecution


Policyfactors










CivilWorks:MaharashtraINFRASTRUCTUREDEVELOPMENTWING(IDW) AdequatestaffingofIDW:

• HeadedbyaSuperintendentEngineer(ondeputationfromthePWD)

• OneExecutiveEngineer,oneDeputyEngineer,twoJuniorEngineersand3ProgramAssistants.

• OneExecutiveEngineerineachofthe8(administrative)Circlesinthestate.

• OneDivisionalEngineerforapproximatelyevery4districts.

• OneDeputyEngineerineachdistrict.

a. PWDunitwithintheZillaParishadsresponsibleforconstructionworksforabout13departments– excessivedelaysinexecution.

b. IDWwassetuptoexpediteconstructionworksundertheNHM.

c. ItbeganwithmajorandminorcivilworksundertheDistrictHealthOfficer(allSCandPHCs)– allworksuptoRs50lakhs

d. In2015-6agovernmentorderwasissuedforhandlingoverallallconstructionworksforCHCsandDHstotheIDW.

e. AllnewconstructionundertakenbyIDWandthenthefacilityishandedovertothePWDforongoingmaintenance.


CivilWorks:MaharashtraINFRASTRUCTUREDEVELOPMENTWING

• EstimatesofallworksareincludedintheNHMplans.

• Forbudgeting,PWDScheduleofRatesascurrentlyapplicableareused.

• Alltendersareissuedthroughe-tenderportalattheCirclelevelbytheExecutiveEngineer.

• Turnaroundtimeisdefinedforcompletingthetenderprocessfordifferentsizesofworks:25daysforworks>Rs2.5million,15daysforworksbetweenRs1.5millionandRs5million;and7daysforworks<Rs1.5million.

• Timelinesarealsodefinedfordifferentprocessespriortoissuanceofe-tender:preparingdetailedestimates:15days;technicalsanctions:15days;BOQ&tenderpreparation:7days

Source:IDWadministrativerecords,SHS,Maharashtra

33%

99% 98%

76% 81%

100% 99%

71%

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15

UtilisationoffundsbytheInfrastructureDevelopmentWing,NHM,Maharashtra


CivilWorks:Rajasthan

DedicatedcellwithintheDepartmentforCivilWorks:withapproximately15staffdeputedfromthePWD,focusingexclusivelyonhealthdepartmentcivilconstructionprojectmanagementandimplementation.

Steepincreaseovertheyearsinbudgetutilizationofthisexpenditureline.

49%

64% 60%

76%

2012-13 2013-14 2014-15 2015-16

UtilizationagainstbudgetforthelineNewconstruction/renovationandsettingup(NHM)


Budgetexecution


Policyfactors







- Planning&budgeting- Fundflow- Execution&monitoring- Procurement- Civilworks- Humanresource


OperationalFactors: BudgetexecutionandmonitoringHRrecruitmentandmanagement:KERALA

• MedicalRecruitmentBoard– underconsideration• WelldocumentedHRpolicyforNHM• ModelagreementwithcontractualworkersarestandardandbasedontheKeralaServiceRules–

whichensuresstandardizationandtransparency.• Financedepartmentalsohasaccesstopayrollandpersonnelmanagementdatabase.• AnnualpayrollauditsareconductedbyAGtoensuretransparency– noghostworkers• Cadrewisemonthlyreview• ServiceandPayrollAdministrationRepository(SPAR)forKeralaisadatabaseonallservicematters.• ConfidentialReportandPerformanceAppraisalisnotincluded.• UnionofASHAs;actionagainstnon-performingASHAs• RecenteffortofmodifyingthejobdescriptionofANMstoincludenon-communicabledisease

relatedservices.

OperationalFactors: BudgetexecutionandmonitoringHRrecruitmentandmanagement:MAHARASHTRA

• Twostructuresatthedistrictlevel:DistrictHealthOfficermanagesthePublicHealthSystemandtheclinical/hospitalsideismanagedbytheCivilSurgeon.

• PublichealthstreamisintegratedwiththeZillaParishadandlocalselfgovernment.

• Around2009recruitmentofdoctorswasshiftedfromMaharashtraPublicServiceCommission(MPSC)toMaharashtraKnowledgeCorporationLimited(MKCL).RecruitmentsthroughMKCLnowtakeabout2– 3monthsasagainst2yearstakenbytheMPSC.Thishassignificantlyimprovedtheavailabilityofmedicalofficersacrossthestate.AsHRconstitutesalargeshareoftotalexpenditure,thiscontributestohighutilizationrates.

• Toaddressthegapofspecialists,in2009theGovernmentrecognizeddiplomasfromCollegeofPhysiciansandSurgeons(CPS)inMumbaitoconvertMBBSdoctorsintospecialists.Approximately1000MBBSdocsareworkingasspecialistsinMaharashtraholdingCPSdiplomas.


Budgetexecution


Policyfactors








ElementsofLeadershipandGovernanceHighlevelsofpoliticalsupport but minimalinterference

Stability intenureatseniorpositions

Strong: withDepartmentsofFinance,Planning,PRI

Willingnesstoexperiment– takerisks

Monitoring results, not expenditure

At all levels

Effective devolution of powers

PoliticalSupport

Stability

Inter-departmentalcoordination

Culturetoinnovate

Focusontechnicalefficiency

Focusoncapacitybuilding

Strong localleadership

Leadership&Governance

PoliticalLeadershipandSupport

• Strongpoliticalsupport,minimalinterference• VisiblespeciallyinKeralaandRajasthan• Proactiveinterestinsocialsectors

• Rajasthan:CMInformationSystem:monthlyreportsbyDepartments• GuardianMinisterinMaharashtra:eachdistrictisassignedtoaMinisterforoverseeingall

developmentactivities.• DevelopmentPlanningCommittee(DPC)ischairedbytheGuardianMinisteroftheDistrict.

GovernmentappointsoneGuardianMinistertoeachdistricttooverseeitsdevelopmentplansandrelatedaffairs.DPCorganizesdepartmentwisemeetings.

Leadership&GovernanceStability• Stabilityintopleadershippositions:atthelevelsofAdditionalChiefSecretary,PrincipalSecretary,

MissionDirector,NHM• Allowsspaceforexperimentation

Interdepartmentalcoordination• Strongcoordinationbetweendepartmentsoffinance,PRIsandplanning:

(PuneZillaParishad:providedaboutRs70millionforhealthin2015-16andthisincreasedtoRs112millionin2016-17)

• StrongerlinkageswiththepanchayatatdistrictlevelvisibleinKeralaandMaharashtra

CulturetoInnovateThisspiritwasechoedbyofficersatthestate&districtlevelinKerala.

Promotionofaculturetoinnovate,andexperiment– drivenbytheleadership–PrincipalSecretaryandtheChiefMinisterareopentonewideasandhaveriskappetite:enablessecondlineofleadershiptoinnovate…

NHMMissionDirector,Rajasthan

Leadership&GovernanceFocusontechnicalefficiency

• Reflectedinapproachtomonitoring• StrongerinRajasthanandKerala

Transparency:RajasthanisprobablytheonlystatewithmonthlyNHMFMRsuploaded,physicalandfinancialprogressreport(monthly)ofallcivilconstructionworksuploaded

Leadership&Governance

Strong localleadership

••Willingtotakedecisions••Willingtotakerisks••Motivatedtoperform

Stronglocalleadership

• Dynamicandaggressiveleadershipatthedistrictlevel.

• Engagedleadershipobservedduringdiscussionswithofficialsinall6sampleddistricts.

• Factorsresponsible:

Supportive supervisionfromstateLeadership – nocultureofblamegame

Devolvedpowers&responsibilitiesMinimalinterferencefromthestate

Strong coordinationwiththeLocalSelfGovernment


Budgetexecution

Arethereanypolicyfactors thatenablebetterexecution?

Policyfactors

Arethereanyoperational/processfactorsthatenablebetterexecution?


Arethereanyoperational/processfactorsthatenablebetterexecution?


Arethereanyhumancapacityfactorsthatenablebetterexecution?



Institutional&HumanCapacityFactorsKerala

- VoluntaryTechnicalworkingGroupssetupinKeralaondifferentissuestostrengthencapacityforstrategicthinkingandplanning.

- AllDistrictProgramManagers(DPM)aredoctorssecondedfromDHSwhichallowsforverygoodconvergence/alignmentofNHMandStateplans.GoodcoordinationbetweenDPM,DistrictMedicalOfficerandDistrictRCHOfficer.

- Governmentcancontractconsultantsonsanctionedgovernmentposts.

Rajasthan- PositionofBlockCMOscreated(2008).BlockCMOsaredifferentfromCHCin-charge,havefull

administrative&financialpowersandareresponsibleforcoordination&managementallpublichealthfunctionswithintheblock.Priorto2008,eachblockhadaDeputyCMOwithnoadministrativeandfinancialpowersandsupport.

- Around2013,thepostofAccountsOfficerwascreatedatthedistrictlevel(ondeputationfromRajasthanAccountsServices)intheDPMUnotonlyforaddingcapacitybutalsoforgreateroversightbythestate.

Institutional&HumanCapacityFactorsMaharashtra

- DedicatedcellinPuneforallfollowupsandcoordinationwiththeNHMteamofGoIforensuringcompliancetoallrequirements,timesubmissionandtimelyreceiptoffunds

- OnlineHumanResourceManagementSystemsforNHM

- Wellestablishedpublichealthcadre

- DedicatedHRCellformanagingHRfunctions

- Forthepurposesofadministeringtheactivitiesofthehealthdepartment,thestateisdividedinto8Circles

- EachCirclehasanadministrativeunitheadedbyafullyempoweredDeputyDirectorHealthServicesformentoring,monitoringandoversight

- RecognizingcoursesoftheCollegeofPhysicians&Surgeonsforspecialists



Fiscal Attributes, Health financing attributes3




5

6

Whatfollows…

Conclusion and recommendations7

ExamplesofcurrentpracticesyieldingbetterresultsRegularfundsavailabletodistrictsthroughouttheyear

• Inthelasttwoyearsmorethan50%ofthethetotalNHMfundsaretransferredtothedistrictsonlyinquarter4.

• HighallocativeprioritytoMFPfundsinKeralaandRajasthan.In2014-15:o DistrictsinKeralareceived88%offundsMFPwithin

Q3.o DistrictsinRajasthanreceived65%ofMFPfunds

withinQ3.

InUPsubstantialportionsofMFPfundsaretransferredonlyinthelastquarter.

40% 31%

42%

10% 26%

73%

12%

35%

64%

Kerala Rajasthan UttarPradesh

ShareofMissionFlexiPoolfundstransferredtodistrictsinquarter4

2012-13 2013-14 2014-15

Kerala,Maharashtra&Rajasthan:betterabletoavailoftheflexibilityMFPaffords

• Kerala:morethan50%ofNHMbudgetisforMFP.Utilizationis80%in2015-16.

• Maharashtra:almosthalfofNHMbudgetisallocatedtoMFP.Hadhighutilization,increasinglyfacingliquidityproblems

• Rajasthan: allocations&utilizationgraduallyincreasing.

5565

5460

44 4134 40 44

36 34 33

58

34

77

63 55

9080

68

43

64 63

42 4740

23

53

2012

-13

2013

-14

2014

-15

2012

-13

2013

-14

2014

-15

2012

-13

2013

-14

2014

-15

2012

-13

2013

-14

2014

-15

2012

-13

2013

-14

2014

-15

Kerala Maharashtra Rajasthan Bihar UP

MissionFlexipoolBudgetShare&Utilisation(inpercentage)

BudgetShare Utilization

Bihar&UPLessMFPallocation,lowutilization


Spaceandabilitytoinnovate

Significantlyhighutilizationoffundsforinnovations(underMFPofNHM)inKerala&Maharashtra– stateswithstrongercoordinationwithPRIs

Willingnesstoexecutebudgetlinesthatneeddiscretion,localplanningandleadership.LimitedwillingnessinBiharandUP

142%

98%

19%

71%

100%

14% 23%

79% 68%

37%

Bihar Kerala Maharashtra Rajasthan

UtilisationofInnovationbudgetlineunderMFPinNHM

2012-13 2013-14 2014-15

UPFMRdoesnotincludeInnovationsbudgetline(B14)Bihar2012-13nobudgetRajasthan2012-13nobudget


ExamplesofInnovationsfundedunderNHM:

Kerala:

• Palliativecare• Genderbasedviolence• CommunityMentalhealth

program• RadioHealth• Schoolquizprogram• Settingupofdialysisunit• Doctor-on-call• Dialysisunits• RehabilitationofEndosulfan

(pesticide)victims

Maharashtra:

• HealthAdviceCallCenter(Tollfree:104)

• Telemedicine• Organisationofspecialist

medicalcampsthroughMedicalCollegesintribalareas– tostrengthenoutreach

• CoordinationCellforTribesinselectedtribalDistrictHospitals

• Screeningoftestingofcervicalcancerinruralareas

Rajasthan:

• Outsourcingofcleanlinessinhospitals;

• ASHASoft,• Gradingoffacilities

(incentivizingbestperformingCHC,PHC,SC

• Trackingoflowbirthweightinfants

• Hardareaincentive• HRMIS• Skillsassessmentofnursing

staff


EmpoweredandstronghospitalsocietiesleadingtogoodutilizationofbudgetforCorpusGrants

• Theydeveloplocalplans.• Takespendingdecisions.• Districtsmonitortheexpenditure• Includingmonitoringthegovernance

andfunctioningoftheRKS• Panchayatsplayaproactiverole

ResultsarereflectedintheutilizationratesinKerala,Maharashtra&Rajasthan

2014-15 onwardstheCorpusGrantbudgetlineinNHMFMRwasmergedwithUntiedGrants.

98%

130%

102%

126%

84% 79% 96% 100%

129%

85%


UtilisationofCorpusGrantunderMFPinNHM

2012-13 2013-14


LocalneedsmetthroughutilizationofUntiedGrantsavailableunderNHM

Willingnesstoexecutebudgetlinesthatneeddiscretion,localplanningandleadership.

ConsistentlyhighutilizationinMaharashtra.

UPstateanalysisdidnotinclude2014-15

77%

114%

92%

67%

45%

68%

96% 93% 89% 75%

36% 52%

89%

67%


UtilisationofUntiedGrantsunderMFPinNHM

2012-13 2013-14 2014-15


Renovationofoldandcreationofnewhealthinfrastructure

InstitutionalcapacityforexecutinginfrastructureprojectsisstrongerinKerala,MaharashtraandRajasthan(thanUPandBihar).Therebycontributingtoincreasesoverallfundutilization.

UP:Nobudgetin2013-14forthis line.Expenditurebooked:Rs46.87croresUPstateanalysisdidnotinclude2014-15

7%

41%

94%

49%

7% 7%

42%

88%

64%

34%

84%

33%

60%


UtilizationofNewConstruction/RenovationbudgetlineunderMFPinNHM

2012-13 2013-14 2014-15


UtilizationofmostofthefundsavailableattheStateHealthSocietiesinKerala,MaharashtraandRajasthan

If100%ofavailablefundswereutilizedattheSHS,theTGHEwouldincreaseby49%inBiharin2013-14andby26%inUPin2014-15.

SystemicinterventionneededtoaugmentthefundutilizationcapacitiesofSHSinBihar&UP.

31

103 10598

4339

105

79 76

36

57

103

84 79

41


UtilizationofavailablebytheStateHealthSociety(inpercentage)

2012-13 2013-14 2014-15

SHS inKerala,MaharashtraandRajasthanutilize80%to100%ofthefundsavailable(includingopeningbalances&interestsearned)withthem.

ContrastwithUP&BiharwherealmosthalfthefundswithSHSremainunutilized.








5

6

Whatfollows…

Conclusions and recommendations7

Contrastingcapacitiesbetweenstates

Planning capacity at lower levels

Evidence for planning, HMIS

Bihar&UP

KeralaMaharashtraRajasthan

Cash forecasting and monitoring capacity

Lower levels of governance

empowered to take decisions

Coordination with local government units(Panchayati Raj

Institutions)

Poor quality of plans, un-realistic budgets

Greater negotiation time, delayed approvals

HighYesStrongHigher

Lower

Stronger Toalargeextent Higher

Weaker Toalimitedextent Lower

Uneven flow of funds; when funds are

available, no time for implementation

Approvals from the state;

Administrative delays;

Lack of ownership

Challenges in implementing local innovations, flexible

funds and responding to local needs

Contrastingcapacitiesbetweenstates

Coordination between NHM and non-NHM

verticals

Bihar&UP

KeralaMaharashtraRajasthan

Quality & nature of mentoring &

handholding from higher levels

Reliance on e-platforms for expenditure &

outcome monitoringPolitical interference

Fragmented implementation;

Missing on synergistic gains

HighYesStrongHigher

Relativelylow

Strong High Limited

Relatively weak Morelimited Higher

Lack of focus on results

Inadequate capacity at the implementation

level

Ineffective monitoring;Lack of real-time

information for actionLimited evidence for

mid-course corrections

Local needs hostage to political priorities







5

6

Whatfollows…

Conclusion & recommendations7

Toconclude...

StableleadershipStronggovernance

Decentralizedpowers

StrongconvergenceVHSNC,RKScapacityProcurementcapacity

ITformonitoringFocusonresults,not

expenditure

ImprovedPlansImproved

Implementation

StrategicMonitoring–

priority/focusareas

Betterfundutilization

Betterhealthoutcomes

OverallrecommendationsDeepdivesreveal

• Noonesinglebigfactororpracticeexplainsincreasedutilizationoffundsinthehealthsector.Rather,rangeofsmallercomplementaryactionsinpro-performanceenvironment.Nosinglethingtoadoptandscale-up.

• Changesinexistingpracticeso toimproveplanningandmonitoringcapacity,o tomakeleadershipmoreproactive,committedandlessriskaverse,o toprovidegreaterempowermenttodistricts,ando toenhanceaccountabilitymeasures

createanenablingenvironmentforhighbudgetutilization.

• Someofthespecificrecommendations:(a)relatedtopolicy&PFMmeasures;and(b)relatedtoprocesses.

Specific recommendations….

Recommedations:RelatedtoPolicy&PFMSystems

- DevelophealthstrategyembeddedintoSDGs(likeKerala)- Alignstrategicplanandmediumtermbudget- Providegreaterautonomytodistricts

01

- Streamlineplanpreparationprocessandapprovaltimelines.- AlignNHMplanningprocesswithstateplanning&budgeting 02

- Improvepredictabilityofin-yearresources(improvefundflow)- ImprovepayrollcontrolmeasuresthroughITbasedHRMIS

03

- AlignNHMbudgetclassificationwiththestatebudgetclassificationsystem- Developasystemforintegrationofexpendituredataacrossbudgetsources

forcomprehensiveandintegratedexpendituretracking.04

- StrengthenqualityofinternalandexternalauditsunderNHM- EnablepublicaccesstoNHMfinancialinformation(FMR,fundtransfersand

positions,SHSauditreports)05

- Undertakeperiodiceconomicanalysisofhealthexpenditure.- Resultstoinformfutureplanning,investmentandallocationdecisions. 06

Recommedations:RelatedtoPolicy&PFMSystems

Recommendations:RelatedtoProcesses

Provide greater autonomy to districts- Decentralizedecisionmaking,avoidmicromonitoring- Reduceriskaverseapproachtomanagement- Limittheroleandinterferenceofthestate

01

Develop human capacity- Forplanningatlocallevels- Forresultbasedmonitoring

03

Develop institutional capacity- Forprocurementofdrugsandmedicalequipment- Formanagingcivilworks

02

Use IT for monitoring- Integratedsystem- Linkedfinancialmanagementwithprogram

outcomes

04

Strengthen communitization efforts- OfVillageHealth,Sanitation&Nutrition

Committees- OfHospitalSocieties

06

Strengthen linkages withLocal Self Government05

Nextsteps...

• Currentdeepdivesprovideanoverviewofthefactors.

• Statespecificdiagnosismayberequiredinlowperformingstatestoassesswhatistransferableandscalableanddevelopaplanofaction.

Ø PeterBermanE:[email protected]

Ø ManjiriBhawalkarE:[email protected]

Ø RajeshJhaE:[email protected]

Thankyou

Documents

Factors that contribute to high health budget execution ABC · 9/1/2017 · Comparison to Bihar & Uttar Pradesh 5 6 ... - PEFA 2016 Framework - Budget, expenditure analysis - Qualitative