Abt Associates Inc.

In collaboration with:

Broad Branch Associates | Development Alternatives Inc. (DAI) | Futures Institute | Johns Hopkins Bloomberg School of Public Health (JHSPH)

| Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)

Ministry of Health / Ministry of Finance

Toolkit

December 11, 2014

Montreux, Switzerland

Y1 CB Activity 6: Toolkit for MOH to work

more effectively with MOF

What is the problem?

MOH and MOF lack common language, systems, priorities, and

incentives

Few opportunities exist for dialogue on priorities and funding

MOH compete with other sectors for limited resources

MOH needs to be prepared to answer questions such as:

Did you spend all the resources allocated to health?

How did you spend those resources?

What results did you generate?

How can resources be spent more efficiently?

HFG’s Contribution

Five tools focused on improving MOH ability to demonstrate

performance, accountability, efficiency and responsiveness.

Guided Self-Assessment of Public Financial Management

Performance

Self-Assessment of Internal Control

Developing Key Performance Indicators for Health

Collecting Data for Efficiency

Conducing Health Sector Performance Audits (2015)

What’s in a HFG Tool?

Tools targeted at MOH officials directly involved in functions

associated with MOF collaboration.

Description of problem, issue

Step-by-Step process

Templates and tables

Country example

Tool 1: Guided Self Assessment of Public

Financial Management Performance

Adapting the Public Expenditure and Financial

Accountability (PEFA) review for the health sector

Focus on 12 (of 31) indicators most relevant to health

Providing MOH officials a macro level view on PFM to:

Develop PFM roadmap

Respond to MOF request for fiduciary assessment

Provide policy makers with risk assessment

Inform MOH internal review cycle

HFG Tool Indicators

1. Expenditure against original budgets

2. Monitoring expenditure arrears

3. Public access to fiscal information

4. Medium term planning, budgeting and spending

5. Cash flow predictability

6. Payroll controls

7. Transparent procurement system

8. Formal internal control

9. Internal audit effectiveness and accountability

10. Strength of accounting system

11. Data generated by accounting system

12. Use of donor financial information for budgeting and reporting

Self-Assessment of Public Financial

Management Performance

Score Minimum Requirements

A MOH makes available 5-6 of the 6 listed types of information

B MOH makes available 3-4 of the 6 listed types of information

C MOH makes available 1-2 of the 6 listed types of information

D MOH makes available 0 of the 6 listed types of information

Indicator 3: Public Access to Key Fiscal Information

Tool 2: Internal Control Self Assessment

What is Internal Control?

In pursuit of an entity’s mission, the following general

objectives are being achieved

Executing orderly, ethical, economical, efficient and

effective operations;

Fulfilling accountability obligations;

Complying with applicable laws and regulations; and

Safeguarding resources against loss, misuse and damage

The Self-Assessment Process

Conducted every six months

Estimated 3 to 4 week duration; teams of 2 to 6 people

Sampling of facilities based on rural/urban, geography, and

size.

Report highlights areas of strength and weakness in five areas: Control Environment

Risk Assessment

Control Activities

Information and Communication

Monitoring

Indicators of Internal Control

General

Assessment

Rating

Inadequate (-1)

Needs

Improvement (0)

Adequate (+1)

There is a "Code of

Ethics

The organizational

structure is

supportive of a

control environment.

Tool 3: Key Performance Indicators

Global shift from input-based budgeting to program and performance-

based budgeting, resulting from:

Increasing citizen demands for government accountability and results

Increasing legislative scrutiny of government operations

Tighter budgets and the need to economize and justify spending

What are KPIs? Measures used to define success and track

progress in meeting strategic or long-term goals.

Used to: Establish baselines; Set performance standards; Measure

and report improvements over time; Compare performance across

geographic locations; Benchmark performance against regional and

international peers; Allow stakeholders to independently judge health

sector performance.

Linking KPIs to Strategy

Using a Logic Model to Sharpen Focus on Strategic Plan Goals

Problem or Need Policy Goal

People mostly visit health centers when they

experience illness or injury, not as part of routine or preventive health maintenance, driving up healthcare

costs and the incidence of preventable medical

conditions.

Create incentives for proactive health

maintenance (e.g., reduced-fee or free

preventive visits), and/or disincentives for

unhealthy habits (e.g., “sin taxes” on the

consumption of specific items, such as tobacco or

alcohol).

To reduce morbidity and its costs to society through enhanced

incentives to practice healthy lifestyles.

…and from Strategy to Programs

Figure 2. Logic Model for Program Planning

doctors, medicines,

clinics

routine exams, screening,

vaccination, health

education

reduced emergency

visits, hospital admissions,

etc.

reduced morbidity/

reduced healthcare

costs

Inputs Activities Outputs Outcomes

Challenges with using KPIs

Making KPIs “SMART” – Specific, Measurable, Achievable,

Relevant, Time-bound

Linking country strategies to programs, and programs to

budgets

Generally part of a whole of government initiative to move

towards performance budgeting

Requires a change in organizational structure and

incentives

Takes time to implement

Tool 4: Data for Efficiency

Issue: Expanding “fiscal space” for health can also come from

efficiency gains. How can MOHs properly assess internal efficiency

across their operations (i.e. deployment of health personnel;

utilization of medical products and technologies; and use of health

facilities and care)?

Objective: Tool helps to understand and assess efficiency in the use

of resource inputs, illuminating “pain points” allowing MOHs’ upper

management to:

Assess management performance

Strengthen budget preparation and justification in the annual budget

preparation process

Assist in health planning and policy—understanding where to focus efforts to

improve health services.

Defining Efficiency in Health Care

Productive

Efficiency

Technical

Efficiency

Allocative

Efficiency

Definition Outputs cannot be

produced with less of

some input

Outputs cannot be

produced at lower cost

No person can be made better off

without making someone else

worse off

Opportunity Reduce waste Save money Maximize social value

Sample

Inefficiencies

1. Excessively low

bed-occupancy rate

2. Expired drugs and

IV fluids

1. Unnecessary use of

antibiotics

2. Inadequate lengths of

stay

1. Bednets versus polio vaccines

2. Wrong scale and scope in

hospitals

Efficiency in Health Care:

Sample Indicators

Staff Utilization Health Technologies/

pharmaceuticals

Health Facilities

Density of physicians/nurses Percent use of generic drugs Ratio of Administrative Cost

to Total Cost

Patient loads and time spent

with patients

Minimization of waste in

medicines (% destroyed)

Service Wait Times

Ratio of wages outlays to

G&S spending

Lab turnaround time Average Length of Stay

(ALOS)

Health workers attendance

rate

Usage levels of high-value

equipment

Bed Occupancy Rate (BOR)

Data Collection, Reporting and Use

Data might or might not already be available

If not, plan surveys across geographic areas and health

facilities (primary, secondary tertiary).

Prepare on a yearly basis

Used for internal purposes, but also….

….as input for budget justifications to the MOF, including:

Successes in health resource use (productivity and utilization

rates)

Issues, findings and recommendations

MOH efforts/initiatives for attacking issues

Tool 5: Performance Audit for Health

(2015)

• Why performance audit?

• Who is the primary audience for this tool?

• What expertise is required to conduct a performance audit

(and to use this tool)?

• What are the key steps in conducting a Performance Audit?

Planning – setting objectives; audit questions; indicators of

performance; sources of evidence etc.

Field work

Reporting

Follow up

Abt Associates Inc.

In collaboration with:

Broad Branch Associates | Development Alternatives Inc. (DAI) | Futures Institute | Johns Hopkins Bloomberg School of Public Health (JHSPH)

| Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)

Thank you

https://www.hfgproject.org/