I have become a manand When I was a child, I talked like a child, I thought like a child, I reasoned...

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When I was a child, I talked like a child , I thought like a child, I reasoned like a child; now that I have become a man, I am done with childish ways and have put them aside 1 Corinthians 13: 11

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Transcript of I have become a manand When I was a child, I talked like a child, I thought like a child, I reasoned...

Page 1: I have become a manand When I was a child, I talked like a child, I thought like a child, I reasoned like a child; now that I have become a man, I am done.

When I was a child, I talked like a child , I thought like a child, I reasoned like a child; now that I have become a man, I am done with childish ways and have put them aside 1 Corinthians 13: 11

Page 2: I have become a manand When I was a child, I talked like a child, I thought like a child, I reasoned like a child; now that I have become a man, I am done.

General Government Health Expenditure

Solomon Huruva Mukungunugwa

Health Systems Policy

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Presentation Outline

• Methodology• Definition of GGHE & Health Systems

Financing• Purchasing Health Services 2009-2012• The rhetoric• Concluding remarks

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Health (Systems) Policy Analysis

An analysis

OF &

FOR

Policy

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Definition

• General government (excluding social security) expenditure on health refers to expenditures incurred by central, state/regional and local government authorities, excluding social security schemes. Included are non-market, non-profit institutions that are controlled and mainly

financed by government units.– Mandated by law (by-laws; acts of parliament)

Source OECD

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Revenue Collection

• General taxes – Biggest contribution– Direct & indirect taxes

• Payroll tax– Aids Levy

• 3% of taxes • Contributes to 35% national ART requirements (2012)

• Social health Insurance: 0%

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Pooling

• All revenue is collected by Zimra on behalf of Ministry of Finance

• MOF becomes the aggregate pool & purchaser for GOZ

• Except earmarked taxes which are sent directly to the beneficiary entities – National Aids Trust Fund

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2009 2010 2011 2012 2013 $-

$50

$100

$150

$200

$250

$300

$350

$400

$450

Budget allocation 2009-2013

fiscal year

bu

dg

et

allo

ca

tio

n M

illio

ns

$

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Budget release 2009-2012

2009 2010 2011 2012 2013

budget allocation 1 1 1 1 1

actual release 0.946933037887872 0.946933037887872 0.86240232527186 0.799480419019463 0.86796992013535

5%

15%

25%

35%

45%

55%

65%

75%

85%

95%

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Purchasing

• HRH– GOZ only paying 33-45% of salaries for staff in grade

C5 and above

• Non wage – Transaction costs– Capital expenditure– Recurrent expenditure

• Medicines, commodities & logistics– Non ARV (PHP under EU U$17m)– ARV ( GFATM, USG, DFID, NATF etc)

• Health Information Systems (CDC, GFATM)

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National Budget breakdown MOHCC 2009-2012 FYs

2009 2010 2011 2012 2013

wages 36.6498 72.689102 152.723 197.785 164.878871

non wage aapropriations 121.024 86.5976000000002 79.675 114.89 53.128094

5%

15%

25%

35%

45%

55%

65%

75%

85%

95%

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What are non-wage appropriations?

• Recurrent appropriations– Health services

• Hospitals• Clinics• programs

– General health services• Foreign travel, maintenance & other enablers

– Capital expenditure• Equipment• Vehicles etc

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Transaction costs..

MOHCCLevel Annual

Transaction Costs 2013

HQ U$ 2.1m

Provincial (PMD) U$20,000

District (DHE) survive on HSF collections & donations

NACLevel Annual

Transaction Costs (2005) by proportion

HQ 94.3%

Provincial (PAC) 5.2%

District (DAC) 0.5%

Sources : MOHCC Finance Depts. & Mpofu A; Nyahoda P: National Health Financing in Zimbabwe 2005: Contribution of National aids levy to National health Care Support

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Mashonaland Central per capita budget 2009-2012

2009 2010 2011 2012

budget 1.64 1.82 1.64 0.91

release 0.45 1.11 0.92 0.53

$0.10

$0.30

$0.50

$0.70

$0.90

$1.10

$1.30

$1.50

$1.70

$1.90

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The scary bit..

• Provinces get episodic releases– This budget accrues to all cost centres in the

province– Many are still paying outstanding bills from

2009-2012– Suppliers behaved like predators

• The transition from Z$ to U$ ( heuristic pricing !)

• Actual budget for current fiscal release approaches $0

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Abuja declaration

• 27 April 2001• Spend at least 15% on health• AIDS an emergency; calling on

comprehensive strategy to mobilise ALL sectors of society– Disease control oriented– No systems for accountability

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Health expenditure trends vs.. Abuja target 2009-2013

2009 2010 2011 2012 20130%

2%

4%

6%

8%

10%

12%

14%

16%

abuja target HE % Total Govt Exp HE %GDP

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Government priorities

The DIPI (domestic index of priority investment) ( a new idea)

• It expresses the ratio (very simplified)

Domestic expenditure per unit of disease burden

Government budget per capita

• HIV : unit of burden is the number of people living with HIV

= $15m/2 million people (approx)

= $7.50 per unit of disease burden Source Robert Greener (internal to GFATM unpublished)

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Thus..

DIPI for HIV in Zimbabwe for 2012 is

$7.50/$0.53 = 14 • This is extremely high!• In SADC the median is 0.27 and Tanzania its 1• HIV patients are better off here than anywhere

else compared to the rest of the patients in the public sector

• NAC runs on earmarked taxes & 50% goes directly to care & treatment!!

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TOP 6 BUDGET ALLOCATIONS GOZ 2010-2014

  2010 2011 2012 2013 2014

1Education Education Education Education Education

2Finance Health Health Health Defence

3Health Finance Defence Defence Home affairs

4Home affairs Defence Home affairs Home affairs Health

5Higher & tertiary education Home affairs

Higher & tertiary education

Higher & tertiary education

Higher & tertiary education

6Defence

Higher & tertiary education Finance Finance OPC

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GOZ non wage expenditure viz a viz WHO health system financing guideline

2009 2010 2011 2012 $-

$5

$10

$15

$20

$25

$30

$35

$24 $24 $24 $24

$33 $33 $33 $33

$0.45 $1.11 $0.92 $0.53

fiscal year

op

erat

ion

al e

xpen

ditu

re p

er c

apita

exc

l wag

es

WHO UPPER LIMIT

GOZ MC MOHPROVINCIAL ALLOCATION

WHO LOWER LIMIT

Assumption guide $60/ capita & wages constitute 45-60% of expenditure

High (UL)

66 x times growth in provincial budgets

Moderate (LL)

48 x times growth in provincial budgets

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The sum total is …

• GGHE does not protect citizens against catastrophic health expenditure– Budgeting is historical – Needs to be based on essential benefits

(systems based)– Benefit package part of social contract!

• If anything it predisposes citizens to impoverishment.– You better off being HIV+ ONLY!!

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Government health expenditure in Zimbabwe is geared to funda) The bureaucracy & not the system ( community )b) HIV

Page 24: I have become a manand When I was a child, I talked like a child, I thought like a child, I reasoned like a child; now that I have become a man, I am done.

Every system is perfectly designed to perform & produce the results that it does…


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