crawford school of public policy - tracking health expenditures in papua new … · 2015-02-17 ·...
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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
3
198
5
198
7
198
9
199
1
199
3
199
5
199
7
199
9
200
1
200
3
200
5
200
7
200
9
201
1
201
3e
201
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
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• 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%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
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
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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
0
200
400
600
800
1000
1200
1400
1600
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%
0%
5%
10%
15%
20%
25%
30%
35%
40%
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...
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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
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847.5
727.1
496.2455.8
253.5
62.319.8 2.3
365.8
0
100
200
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600
700
800
900
1000
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
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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