Health Sector PERS
PREM Public Expenditure
Management Course
April 2007, Washington, D.C.
George Schieber
Consultant
Human Development Network
Organization of Presentation
•
•
•
•
•
•
•
Health Systems Reform
Underlying Health Dynamics
Health Expenditures
Basics of Health Financing
Provider Payment
Basic Health Reform Issues
Basic Reform Instruments
Health Systems Reform
Objectives of Health Systems
•
•
•
•
Improve health status of population
Assure equity and universal access
Provide financial protection
Be efficient from macroeconomic
and microeconomic perspectives
• Assure quality of care and consumer
satisfaction
Complexity of Health Sector
•
•
•
•
•
•
•
•
Global governance and policy coherence is a major problem as there are
well over a 100 major organizations involved in the health sector, far more
than in other sectors (e.g., unstructured plurality).
As the bulk of the funding needed in the health sector is for long term
recurrent costs as opposed to the more traditional short term investment
costs, countries need to figure out how to create adequate future fiscal
space in their budgets for sustainability.
There are numerous non-health related factors that affect health outcomes,
necessitating complex cross-sector approaches.
Individual behavior plays a critical role in health outcomes and is very
difficult to influence or change.
Measuring health outcomes—other than sentinel events such as births or
death—and attributing causality to specific factors is inherently complex.
The private sector plays a substantial, often predominant, role in both the
financing and delivery of healthcare services and is often absent from the
policy debate.
Market failures in insurance markets and in the health sector more generally
require complex regulatory frameworks.
Finally, the costly financial protection element of health financing is largely
unique to the health sector (except for a few standard social protection
programs) and creates difficult tradeoffs among competing health objectives
for resource constrained governments.
Achieving Change in HNP
Behavior of Individuals/Households
Income
Education
Water
Sanitation
Nutrition
Macroeconomic
Environment
Performance of Health System
•Clinical Effectiveness
•Accessibility and Equity
•Quality and Consumer Satisfaction
•Economic Efficiency
Health Status Outcomes
•Fertility
•Mortality
•Morbidity
•Nutritional Status
Health Care System
Delivery Structure
•Facilities (public & private)
•Staff (public & private)
•Information, Education, &
communication
Institutional Capacity
•Regulatory & Legal Framework
•Expenditure & Finance
•Planning & Budgeting Systems
•Client & Service Information/Accountability
•Incentives
Governance
Projects and Policy Advice
Why Public Intervention?
• Health services with collective benefits
(public verses personal health services)
• Redistribution/Equity
• Health insurance market failures
• Other market failures in the direct
consumption and provision of health
services
Nine Criteria for Establishing a BBP
for Public Spending on Health Care
Catastrophic Cost
Poverty
Externalities
Vertical
Equity
Cost Effectiveness
Public Goods
Horizontal
Equity
Rule of Rescue
Public Demands
Key:
Efficiency criteria
Equity or Ethical Criteria
Political Criterion
Source: P. Musgrove
Underlying Health Dynamics
Why Invest in Health?
Buys more health services
Improves life styles
Reduces job-related risks
Buys more education and other
human capital-related services
Health
Improves political stability,
investment climate, and productivity
Reduces medical spending
Reduces fertility
Increases labor supply and
female labor force participation
Increases saving
Increase in the years of
healthy life expectancy
Source: Salehi, 2004
Income
Wealth
Growth
MDG Approach to Investments in
Health
Extreme Poverty
•Halve, between 1990 and 2015,
the proportion of people whose
income is less than $1 a day.
•Halve, between 1990 and 2015,
the proportion of people who suffer
from hunger.
Safe Water & Sanitation
•Halve by 2015 the proportion of people without
sustainable access to safe drinking water.
•By 2020, achieve significant improvement in the
proportion of people with access to sanitation.
Child & Maternal Health
•Reduce by two thirds, between 1990 and 2015,
the under-five mortality rate.
Primary & Girls' Education
•By 2015, boys and girls
everywhere complete a full course
of primary schooling.
•Eliminate gender disparity in
primary and secondary education,
preferably by 2005, and in all levels
of education no later than 2015.
•Reduce by three quarters, between 1990 and
2015, the maternal mortality ratio.
Communicable Diseases
By 2015, halt and begin to reverse
the spread of:
•HIV/AIDS
•Malaria &
•Other major diseases.
Investments are Needed
Across Many Sectors to Achieve MDGs
% growth government health spending
% reduction U5MR 1990-2015
0%
0%
3%
5%
8%
10%
13%
15%
5% economic growth
-10%
& 2.5% female education growth
-20%
& 2.5% roads growth
& 2.5% water & sanitary growth
-30%
-40%
-50%
-60%
-70%
& 2.5% growth in all
Policies and Institutions Do Matter
Elasticities of MDG Outcomes with Respect To Government Health
Spending
CPIA Index
1.00
2.00
3.00
3.25
3.5
4.00
4.50
5.00
Under Five
Mortality
0.799
0.507
0.215
0.142
0.069
-0.077
-0.223
-0.369
Maternal
Mortality
-0.622
-0.654
-0.687
-0.695*
-0.703*
-0.720*
-0.736*
-0.752*
Underweight
Children Under
Five
TB
Mortality
0.13
-0.087
-0.305
-0.360
-0.414
-0.523*
-0.632*
-0.740*
0.651
0.276
-0.098
-0.192
-0.285
-0.472
-0.659*
-0.847*
* Statistically significantly different from zero at 90% confidence level
Source: World Bank, 2003
Cost-effective Interventions Are Key to the MDGs
•
•
•
•
•
Which interventions to choose?
How to transfer them to many countries?
How to implement them to scale?
How much will they cost?
What kind of supporting environment is
needed?
• Can we monitor their impact?
Reducing Under-five Mortality
How much health will a million dollars buy?
Cost Per DALY
(US$)
Estimated DALYs
Averted Per
Million US$ Spent
Improving care of children under 28
days old (including resuscitation of
newborns)
10-400
2,500-100,000
Expanding immunization coverage
with standard child vaccines
2-20
50,000-500,000
40-250
4,000-24,000
8-20
50,000-125,000
Service or Intervention
Adding vaccines to the standard child
immunizations (particularly Hib and
HepB)
Switching to combination drugs
(ACTs) against malaria where
resistance exists (Sub-Saharan
Africa)
Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 1.3.
Preventing and Treating
Noncommunicable Diseases
How much health will a million dollars buy?
Service or Intervention
Cost
Per DALY
(US$)
Estimated
DALYs Averted
Per Million US$
Spent
Taxing tobacco products
3-50
24,000-330,000
Treating heart attacks with inexpensive drugs
10-25
40,000-100,000
Treating heart attacks with inexpensive drugs
plus streptokinase*
600-750
1,300-1,600
Treating heart attack and stroke survivors for
life with a daily polypill
700-1,000
1,000-1,400
Performing coronary artery bypass surgery in
high risk cases**
>25,000
<40
Using bypass surgery for less severe
coronary artery disease**
Very high
Very small
*Costs and DALYs are in addition to using inexpensive drugs only. **Incremental to treatment with polypill.
Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 1.3
But Economic Growth Will Not Be Enough
Government Health Expenditures/GDP
(assuming 5 percent annual GDP grow th and total health expenditures of $34 per capita)
40.0
Eritrea
Ethiopia
35.0
Ghana
30.0
Projected
Kenya
Lesotho
20.0
Malaw i
15.0
Nigeria
10.0
Uganda
United Republic of
Tanzania
Zambia
5.0
20
07
20
06
20
05
20
04
20
03
20
02
20
01
20
00
19
99
19
98
19
97
19
96
0.0
19
95
Percent
25.0
Underlying Demographics Will Drive Needs/Demands
But Also Have Profound Effects on Economies
High Income
Middle Income
Low Income
75+
7 0 -7 4
2000
6 5 -6 9
6 0 -6 4
5 5 -5 9
5 0 -5 4
4 5 -4 9
4 0 -4 4
3 5 -3 9
3 0 -3 4
2 5 -2 9
2 0 -2 4
1 5 -1 9
1 0 -1 4
5 -9
0 -4
50000
25000
0
25000
50000
200000
100000
0
100000
200000
200000
100000
0
100000
200000
200000
100000
0
100000
200000
200000
100000
0
100000
200000
75+
70-74
65-69
2020
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
50000
25000
0
25000
50000
Notes: Population figures in millions according to standard age stratifications. Projections by World Bank staff.
Demographic impact of HIV/AIDS: Botswana
Population of Botswana with and without AIDS 2020
with AIDS
without AIDS
80
70
60
50
40
30
20
10
0
140
120
100
80
60
40
20
0
20
Thousands
Thousands
Source: U.S. Census Bureau 1999
40
60
80
100
120
140
Inequalities in Outcomes Are an Issue
Child mortality rates for the poor are often two to three times higher than
those for the rich [Source: Asian Development Bank (2006)].
Health Expenditures
Health Policy Baseline
Health Expenditures, 2004
Per capita
Per capita
Per capita
health
health
GDP
expenditures expenditures
($US)
($US)
(PPP)
Under-5
Life
mortality
Total health Public (% total Out-of-pocket External (% Social Security
Expectancy
expenditures
health
(% total health total health (% total health
rate (per
at birth
(% GDP)
expenditures) expenditures) expenditures) expenditures)
1,000 live
(years)
births)
Regions & Income Levels
East Asia & Pacific
Eastern Europe & Central Asia
Latin America & the Caribbean
Middle East & North Africa
South Asia
Sub-Saharan Africa
Sub-Saharan Africa1
1,457
3,801
3,777
1,833
611
732
462
64
250
273
103
27
45
21
251
547
892
307
84
102
58
4.4
6.6
7.3
5.7
4.6
6.3
4.7
39.8
67.8
51.2
49.1
18.8
41.8
43.6
51.1
26.4
36.2
46.1
76.1
26.2
46.8
0.5
1.1
0.4
1.2
1.5
6.8
15.0
17.6
40.5
17.9
11.9
0.9
1.4
0.9
70
69
72
69
63
46
46
37
34
31
55
92
168
168
Low-income countries
Lower middle-income countries
Upper middle-income countries
High-income countries
High-income countries2
533
1,681
5,193
33,929
31,243
24
91
342
3,810
2,778
79
365
676
3,637
2,527
4.7
5.4
6.6
11.2
8.8
23.9
47.3
57.8
60.4
76.0
70.0
42.8
30.2
14.9
16.6
5.4
0.5
0.7
0.0
0.0
1.1
14.4
32.2
26.0
39.3
59
70
69
79
79
122
42
28
7
7
Source: World Bank, WHO, 2007.
:
All regional and income class aggregated data weighted by the series denominator
1. SSA GDP and health spending data excluding South Africa
2. HICs GDP and health spending data excluding the United States
The Global Context:
Major Inequities in Disease Burden
Developing countries account for 90% of the global disease burden
Burden of Disease
34.4%
55.9%
low-income countries
middle-income countries
Source: The World Bank. 2005. World Development Indicators. 2006.
9.7%
high-income countries
The Global Context:
Inequities in Health Spending
…but only 12% of global health spending
Distribution of Total Global Health Spending
2%
10%
88%
low-income countries
middle-income countries
Source: The World Bank. 2005. World Development Indicators. 2006.
high-income countries
But There Are Also Large Inequities in Health
Spending Within Countries
EXPENDITURE PERFORMANCE Can
Be Measured in Many Ways
•
LOCAL CURRENCY
– Point in time or changes over time
– Total nominal spending
– Share of GDP
– Public verses private
– Public health share of all public expenditures
– Administrative expense share
– Type of service
– Capital vs. recurrent
– Nominal per capita
– Real/Volume (health deflator)
– Real/Opportunity Cost (general price deflator)
•
NUMERAIRE CURRENCY--exchange rates/purchasing power
parities (GDP, health)
An accounting perspective of the production of health
The proposed OECD approach
Where Do We Start: National Health Accounts
Coverage and access to services
•Physical
environment;
•Life Style;
•Other socioeconomic factors
Utilisation of
health services
(personal and
collective)
Modification of
health status
Resources
Input into
health services
•
•
•
•
Manpower
Health facilities
Intermediate products
Medical knowledge
and technology
Health
needs
Cost = Price x
Volume
Population health
status
• mortality
• morbidity and QOL
• Earnings
• Fees
• Capital
Investment
• Training/education
• Investment into
medical facilities
• Medical R&D
•
Perceived health
status
• Impairment, Disability,
Handicap
• Multi-dimensional
health status
• Disease-specific morbidity
Expenditure on health by
establishments of providers
• composite health
measures
e.g. health expectancies
Source: OECD
Expenditure on health
by functions
• public health services
• personal services and goods, by
• age group
• disease (ICD)
• ATC (pharmaceuticals)
• DRGs (inpatient care), etc.
Sources of
Financing
(intermediate
and ultimate
financing)
Health Expenditures in Ukraine, 1998-2005
Health System Expenditure &
Financing
(million Ukraine hryvnas)
1998
1999
2000
2001
2002
2003
2004
2005
Total expenditure on health (THE)
6 816
7 721
9 945
12 342
14 174
17 978
22 429
31 340
General government expenditure on
health (GGHE)
3 632
3 838
4 924
6 273
7 457
9 985
12 713
17 612
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
0
0
0
0
0
0
0
0
Private expenditure on health
3 184
3 883
5 020
6 069
6 717
7 993
9 716
13 728
… Private households' out-of-pocket
payment
2 835
3 467
4 492
5 458
6 056
7 175
8 797
11 572
… Prepaid and risk- pooling plans
24
35
50
70
73
84
114
150
… Non-profit institutions serving
households (NGOs)
154
165
196
203
213
231
232
287
External sources
21
18
52
63
80
85
157
198
… of which Ministry of Health
… Social security funds
Source: WHO National Health Accounts 2007
Evolution of Budgetary Expenditures on Health
UKRAINE : - National Expenditure on Health
A. SELECTED RATIO INDICATORS FOR
EXPENDITURES ON HEALTH
1999
2000
2001
2002
2003
2004
2005
5.9
5.8
6.0
6.3
6.7
6.5
7.5
General government expenditure on health (GGHE) as % of
THE
49.7
49.5
50.8
52.6
55.5
56.7
56.2
Private sector expenditure on health (PvtHE) as % of THE
50.3
50.5
49.2
47.4
44.5
43.3
43.8
GGHE as % of General government expenditure
8.6
8.4
8.9
9.3
10.2
9.4
9.4
Social security funds as % of GGHE
0.0
0.0
0.0
0.0
0.0
0.0
0.0
Private households' out-of-pocket payment as % of PvtHE
89.3
89.5
89.9
90.2
89.8
90.5
84.3
Prepaid and risk-pooling plans as % of PvtHE
0.9
1.0
1.2
1.1
1.1
1.2
1.1
External resources on health as % of THE
0.2
0.5
0.5
0.6
0.5
0.7
0.6
Total expenditure on health per capita ($US)
38
37
47
55
71
90
132
Total expenditure on health per capita (PPP)
220
238
279
313
379
427
526
General government expenditure on health per capita ($US)
19
18
24
29
39
51
74
General government expenditure on health per capita (PPP)
110
118
142
165
211
242
296
I. Expenditure ratios
Total expenditure on health (THE) as % of GDP
Financing Agents measurement
II. Selected per capita indicators for expenditures on health
Source: WHO National Health Accounts 2007
Recurrent and Capital Expenditures on Health
Total Government Health Spending (1,000
Ukranian hryvnas)
1999
2000
2001
2002
1,590,487
1,808,013
2,388,559
3,018,550
428,493
557,393
591,616
653,757
1,297,716
1,317,981
1,760,740
2,074,711
Other Current Expenditures
170,904
829,415
1,007,544
1,228,650
Capital
321,104
333,113
490,380
562,246
3,808,704
4,888,217
6,238,899
7,537,914
Percent of Total Government Health
Spending
1999
2000
2001
2002
Wages and salaries
41.8%
37.0%
38.3%
40.0%
Utilities
11.3%
11.4%
9.5%
8.7%
Procurement of items, materials, and services
34.1%
27.0%
28.2%
27.5%
Other current expenditure
4.5%
17.0%
16.1%
16.3%
Capital
8.4%
6.8%
7.9%
7.5%
100.0%
100.0%
100.0%
100.0%
Wages
Utilities
Procurement of items, materials, and services
Total
Total
Source: Ukraine Public Expenditure Review Health Sector , Health Sector Task Force, World Bank 2007
Public Health Expenditures by Program
2004
Percent of Total Health Spending in Ukraine
Program
Government
Private
External
Inpatient
98.0%
2.0%
0.0%
Outpatient
28.4%
71.0%
0.6%
Pharmaceuticals
0.1%
99.9%
0.0%
TB
74.4%
1.3%
24.4%
ARVs
25.4%
0.0%
74.6%
OB/GYN
72.9%
19.2%
7.9%
Other outpatient
84.7%
14.7%
0.6%
Rehabilitative care
54.7%
45.3%
0.0%
Long-term care
100.0%
0.0%
0.0%
Ancillary
24.7%
75.3%
0.0%
Prevention and public health
90.7%
3.4%
5.9%
Maternal and child
11.8%
0.0%
88.2%
Communicable disease prevention
72.2%
0.0%
27.8%
Non-communicable disease prevention
0.0%
0.0%
100.0%
Other
94.9%
3.9%
1.2%
Health administration
97.1%
0.0%
2.9%
Other
97.4%
1.5%
1.1%
Total
58.2%
41.2%
0.7%
Source: Ukraine Public Expenditure Review Health Sector , Health Sector Task Force, World Bank 2007
U.S. NHA By Type of Service
Source: Health Affairs Feb 2007
Total Health Expenditure per capita
($US)
Per Capita Health Expenditure
vs. Per Capita GDP
10000
France
Croatia
1000
Turkey
Columbia
Thailand
100
Lesotho
Cote D'Ivoire
Bangladesh
10
10
100
1000
GDP per capita ($US)
Source: World Bank, WDI, 2007, World Health Organization 2007
10000
100000
Total Health Expenditure (percentage
of GDP)
Health Expenditures as
Percent of GDP
18
USA
16
14
Bulgaria
12
10
Slovenia
Bolivia
Vietnam
8
6
4
India
2
Benin
Algeria
0
10
100
1000
GDP per capita ($US)
Source: World Bank, WDI, 2007, World Health Organization 2007
10000
100000
Public Health Spending Varies Widely By Income Level
Government Health Expenditure
(percentage of GDP)
(Per Capita GDP vs. Public Health to GDP Ratio)
12
10
Portugal
8
Argentina
6
Uzbekistan
4
Ethiopia
Gabon
2
Sri Lanka
0
10
100
1000
GDP per capita ($US)
Source: World Bank, WDI, 2007, World Health Organization 2007
10000
100000
Under-5 Mortality (per 1,000 live births)
Child Mortality Varies Widely for Given Income Levels
(Per capita GDP vs. Under-5 Mortality Ratio)
300
250
200
Azerbaijan
150
Maldives
100
Brazil
Turkey
Spain
Tanzania
50
Ghana
Ukraine
0
100
1000
10000
GDP per capita ($US)
Source: World Bank, WDI, 2007, World Health Organization 2007
100000
Child Mortality Varies Widely for Given Public Health Spending Levels
(Public Health to GDP Ratio vs. Under-5 Mortality Ratio)
Under-5 mortality rate
(per 1,000 live births)
300
250
Burkina Faso
200
150
Botswana
100
Mexico
Iran
China
50
Belarus
Chile
Estonia
0
0
2
4
6
8
Government Health Expenditure (% GDP)
Source: World Bank, WDI, 2007, World Health Organization 2007
10
12
Higher Public Spending on Health Does
Not Guarantee Better Access for the
Poor
Source: WDR 2004
Basics of Health Financing
Health Financing Functions and
Objectives
Functions
Revenue
Collection
Objectives
raise sufficient and sustainable
revenues in an efficient and
equitable manner to provide
individuals with both a basic
package of essential services and
financial protection against
unpredictable catastrophic financial
losses caused by illness and injury
Pooling
manage these revenues to equitably
and efficiently pool health risks
Purchasing
assure the purchase of health
services in an allocatively and
technically efficient manner
Financing Reforms Need to Deal with Revenues, Risk
Pooling, Management and Payment
Revenue
Collection
Public
Taxes
Pooling
Resource Allocation
or Purchasing (RAP)
Government
Agency
Public Charges/
Resource Sales
Mandates
Grants
Social Insurance or
Sickness Funds
Public
Providers
Private Insurance or
Community-based
Organizations
Private
Providers
Private
Loans
Private
Insurance
Communities
Out-of-Pocket
Service
Provision
Employers
Individuals
And Households
Efficiency Gains are Another Source of Financing
* Public spending and child mortality rate are shown as the percent deviation from rate predicted by GDP per capita
Source: Spending and GDP from World Development Indicators database. Under-5 mortality from Unicef 2002`, WDR 2004
Efficiency Defined
• Efficiency of financing base -- the economic
costs resulting from changes in the production
and consumption behavior of firms and
households as a result of taxes and other
revenue raising efforts
• Allocative efficiency – “doing the right things” -purchasing the most cost-effective mix of
outcomes
• Technical efficiency -- “doing things right” –
producing a specific health outcome,
intervention or service at lowest cost
Domestic Resource Mobilization is
Much More Limited in MICs and LICs
Regions
Social Security
Total Revenue Tax Revenue Taxes as % of
as % of GDP as % of GDP
GDP
Early 2000s
Americas
Sub-Saharan Africa
Central Europe, Baltics, Russia & Other
Former Soviet Republics
Middle East & North Africa
Asia & Pacific
Small Islands (Pop. < 1 million)
20.0
19.7
16.3
15.9
2.3
0.3
26.7
26.2
16.6
32.0
23.4
17.1
13.2
24.5
8.1
0.8
0.5
2.8
Low-income countries
Low middle-income countries
Upper middle-income countries
High income Countries
17.7
21.4
26.9
31.9
14.5
16.3
21.9
26.5
0.7
1.4
4.3
7.2
Strong Performance in Most Regions
Real GDP annual percent change
10
9
8
7
6
5
4
3
2
East-Asia &
Europe &
Pacific
Central Asia
Source: World Bank
2004
Latin
America &
Caribbean
2005
Middle-East
& North
Africa
2006
2007
South Asia
2008
Sub-Saharan
Africa
Fiscal
Space* is Needed
Figure 5: Fiscal Space
Increasetoof
*Budgetary room that allows a government
provide resources for a desired
Aid in
purpose without any prejudice Grant
to the sustainability
of its financial position
% GDP
Increase of Grant Aid in % GDP
5
4
3
2
mproved
Improved
Expend.
Expenditure
fficiency
Efficiency in %
GDP
n % GDP
1
0
New Borrowing
Newin % GDP
• Estimates of revenue effort may suggest that an additional 4 percent of GDP could be raised through domestic revenue measures.
•
•
•
•
Borrowing in
% GDP
Negotiations with development partners may elicit indications of an additional 3 percent of GDP in grant aid.
A PER may have identified areas for rationalization that would release 3 percent of GDP in resources for reallocation.
Macroeconomic and debt management may suggest that new borrowing over the period should be limited to 2 percent of GDP.
Seignorage (govt prints money which it loans to itself) is yet another, but generally limited, mechanism for creating fiscal space.
Source: PREM: FISCAL POLICY FOR GROWTH AND DEVELOPMENT: AN INTERIM REPORT, 2006
Improv
Improved
Reven
Revenue
Effort in i
Effort
% GDP
GDP
Fiscal Sustainability is a Critical Concomitant
of the Creation of Fiscal Space
The Classic Definition:
Other Definitions:
•
•
Self-sufficiency -- over a specific time
period, the responsible managing
entity will generate sufficient resources
to fund the full costs of a particular
program, sector, or economy including
the incremental service costs
associated with new investments and
the servicing and repayment of
external debt:

the level of sustainable deficit that will keep the debt
burden constant for feasible rates of growth, real
interest rates, and inflation.

assumes that a constant ratio of public debt to GDP will
ensure public sector solvency and avoid a debt crisis in
the future.

ignores equity and efficiency issues, e.g., can be fiscally
sustainable yet inefficient and highly inequitable.

not very useful for countries with large grant financing.
•
•
The capacity of the health system to
replace withdrawn donor funds with
funds from other, usually domestic,
sources
The sustainability of an individual
program is defined as “capacity of the
grantee to mobilize the resources to
fund the recurrent costs of a project
once the investment phase has ended”
A softer definition is that the managing
entity commits a stable and fixed
share of program costs
Risk Pooling is Needed to Prevent Health
Shocks Which Contribute to Poverty
(Loss of income, excess expenditures in medical health services)
12
10
8
6
4
2
0
Argentina
Chile
Ecuador
Honduras
% of total non-poor population that falls below the poverty and/or indigence line due to
out-of-pocket health expenditures
Source: Baeza
Risk Pooling and Prepayment
• Risk pooling enables the establishment of ‘insurance’ as large
unpredictable risks at the individual level become predictable when
pooled over a large number of individuals
• Risk pooling enables the averaging of health risks over all pool
members and provides the opportunity for redistribution among high
and low risk pool members
• Prepayment provides protection against unpredictable large losses
and redistribution between high and low income individuals:
– In risk rated private insurance, the premium reflects the average
predicted risk of pool members, thus enabling pool members to
face a predictable upfront payment
– In a public system, pre-payment whether through social security
or general revenue contributions allows the separation of
payments from expected medical risks and thus enables
redistribution from high to low income individuals
What do We Mean by Risk Pooling?
Cross-subsidy from
low-risk to high-risk
Cross-subsidy from
rich to poor
(risk subsidy)
(equity subsidy)
Low
risk
High
risk
Poor
Health risk
Rich
Income
Cross subsidy from
productive to non-productive
part of the life cycle
Produ
ctive
Nonproduc
tive
Age
Risk Selection Can Destabilize Insurance
Markets
•
•
•
Adverse selection occurs
when sicker than average
individuals enroll in competing
public or private health
insurance plans
This can destabilize insurance
markets through premium
spirals if healthier individuals
disenroll
Insurers react by trying to
screen out such high risk
individuals by:
– requiring medical exams
– examining claims history
– having waiting periods
– excluding pre-existing
conditions from coverage
– refusing insurance coverage
•
These instabilities can be
offset by:
– regulation of insurers
– marketing insurance to
groups formed for other
purposes (e.g. employment)
– having a mandatory public
insurance program
Insurance Encourages Overuse of
Services
• This phenomenon known as moral hazard results
because of the tendency for insurance to increase
the probability of the occurrence of the event that is
being insured against
• It is present in both public and private insurance
• Insurance design features to mitigate moral hazard
include:
– cost sharing
– limits on benefits
– frequent renewability
– utilization management
Do Insurance Market Instabilities
Necessitate Public Financing?
 Public financing can:
– pool risks over the
entire population
– eliminate adverse
selection and
medical underwriting
problems
– still face cost
problems due to
moral hazard
 Private insurance can:
– segment health risks
by underwriting groups
– preclude economic
losses from coercive
taxes
– allow for greater
consumer choice
Major Health Financing Models
• National Health Service -- systems financed through general
revenues, covering whole population, care provided through public
providers
• Social Health Insurance -- systems with publicly mandated coverage
for designated groups, financed through payroll contributions, semiautonomous administration, care provided through own, public, or
private facilities
• Community-Based Health Insurance -- not-for-profit prepayment
plans for health care, financed through private voluntary
contributions, with community control and voluntary membership,
care generally provided through NGO or private facilities
• Voluntary Health insurance -- financed through private voluntary
contributions to for- and non-profit insurance organizations, care
provided in private and public facilities
• User Fees – charges to individuals for publicly provided services
A Model of the Evolution of Health Care
Financing Systems
Low Income
Countries
Patient
Out-ofPocket
Social Insur
Gov’t Budget
Community
Financing
Middle Income
Countries
High Income
Countries
Priv. insur
Patient Outof-Pocket
Patient Outof-Pocket
National Health
Service Model
Social Insur
National
Health Insurance
Model
Gov’t Budget
Private
Insurance
Model
Source: Modified from A. Maeda
NHS Systems
Systems financed through general revenues, covering whole
population, care provided through public providers
Strengths
– Pools risks for whole
population
– Relies on many different
revenue sources
– Single centralized
governance system has
the potential for
administrative efficiency
and cost control
Weaknesses
– Unstable funding due to
nuances of annual budget
process
– Often disproportionately
benefits the rich
– Potentially inefficient due to
lack of incentives and
effective public sector
management
Social Health Insurance
Systems with publicly mandated coverage for designated groups,
financed through payroll contributions, semi-autonomous
administration, care provided through own, public, or private facilities
Strengths
•
•
•
•
•
•
•
Additional health revenue source
As a ‘benefit’ tax, there may be
more ‘willingness to pay’
Removes financing from annual
general government appropriations
process
Generally provides covered
population with access to a broad
package of services
Often has strong support from
population
Can effectively redistribute between
high and low risk and high and low
income groups in the covered
population
Often serves as the basis for the
expansion to universal coverage
Weaknesses
•
•
•
•
•
•
•
Poor are often excluded unless subsidized
by government
Payroll contributions can reduce
competitiveness and lead to higher
unemployment
Can be complex and expensive to
manage, which is particularly problematic
for LICs and some MICs
Governance and accountability can be
problematic
Can lead to cost escalation unless
effective contracting mechanisms are in
place
Often provides poor coverage for
preventive services and chronic conditions
Often needs to be subsidized from general
revenues
Community-Based Health Insurance
Not-for-profit prepayment plans for health care, with
community control and voluntary membership, care
generally provided through NGO or private facilities
Strengths
•
•
•
•
•
•
•
Community-run and not-for-profit
Membership is voluntary
Promotes pre-payment
Plays a role in mobilizing additional
resources, providing access and financial
protection in LICs
Risk sharing is usually from the well to
the sick
If premiums are based on income, there
can also be risk sharing from the better
off to the poor
CBHI can be a helpful complement but
is not a substitute for NHS or SHI
systems
Weaknesses
•
•
•
•
•
•
Heterogeneous in terms of populations
covered, regulation, and benefits
provided
Providing access and financial
protection are limited due to the small
size of most schemes
The financial sustainability of most
schemes is questionable
CBHI schemes generally do not reach
the very poor
Their impacts on care delivery are quite
limited
Should be encouraged only where more
comprehensive health financing
arrangements cannot be implemented
on a large scale
Voluntary Health Insurance
Financed through private voluntary contributions to for- and non-profit
insurance organizations, care provided in private and public facilities
Weaknesses
Strengths
•
•
•
As a prepayment and risk pooling
mechanism is generally preferable
to out of pocket expenditure
May increase financial protection
and access to health services for
those able to pay
When an “active purchasing”
function is present it may also
encourage better quality and costefficiency of health care providers
•
•
•
•
•
Associated with high administrative
costs
Not effective in reducing cost
pressures on public health financing
systems
May be inequitable without public
intervention either to subsidize
premiums or regulate insurance
content and price
Has the potential to divert
resources and support from
mandated health financing
mechanisms
Applicability in LICs and MICs
requires well developed financial
markets and strong regulatory
capacity
User Fees are Only a Small Share of
Total Consumer Payments
Fees for publicly provided services
Evidence on User Fees is Mixed
Fees for publicly provided services
Strengths
– Generate additional revenue with which
to improve health care quality
– Increase demand for services owing to
the improvement in quality
– May reduce out-of-pocket and other
costs, even for the poor, by substituting
public services sold at relatively modest
fees for higher-priced and less accessible
private services
– Promote more efficient consumption
patterns by reducing spurious demand
and encouraging the use of cost-effective
health services
– Encourage patients to exert their right to
obtain good quality services and make
health workers more accountable to
patients
– When combined with a system of
waivers and exemptions, serve as an
instrument to target public subsidies to
the poor and to reduce the leakage of
subsidies to the non-poor
Weaknesses
– Are rarely used to achieve significant
improvements in quality of care, either
because their revenue generating
potential is marginal or because fee
revenue is not used to finance quality
gains
– Do not curtail spurious demand
because in poor countries there is a
lack, not an excess, of demand
– Fail to promote cost-effective demand
patterns because the government
health system fails to make costeffective services available to users
– Hurt access by the poor, and thus harm
equity, because appropriate waivers
and exemption systems are seldom
implemented; where they are, the poor
get discriminated against with lower
quality treatment
Financing Challenges
•
There is no one ‘right’ financing model.
•
System financing must be sustainable --meaning that future economic
growth generates sufficient levels of income for decent living standards and
external debt solvency.
•
LICs face difficult tradeoffs between financing essential services and
providing financial risk protection -- prioritization is critical.
•
For low income countries receiving large amounts of external assistance,
there are serious questions of absorptive capacity as well as their ability to
finance from domestic resources both future recurrent costs directly financed
by time-limited grants as well as current and future recurrent costs generated
by externally funded investments.
•
Most MICs are challenged to provide universal coverage, reduce
fragmentation among risk pools, and improve purchasing efficiency.
•
The critical issue is risk pooling, whether SHI or NHS is ultimately chosen is
really of secondary importance.
•
The critical condition regarding the speed of evolution to universal coverage
is the level of income and its rate of growth. Evidence also suggests that the
ability to administrate is a key enabling factor for success.
•
Models need to be tailored to individual country circumstances.
Provider Payment
Provider Payment Defined
• Mechanisms used to ‘pay’ medical care
providers/organizations for services rendered to
their clients
• Developing, testing, and implementing new
methods to pay medical care providers (e.g,
global budgets, capitation, DRGs, etc.) including
MIS and QA systems
• Implementing new systems in which:
– money follows patients
– finance is separated from provision
– payment systems contain incentives for access,
efficiency, and quality for public and private providers
Key Messages
1. There is no ‘right’ method
2. Provider payment systems must be tailored to
the institutional realities of each system
encompassing both the demand and supply
sides
3. Policy-makers need to be concerned about
effects across different provider types, different
payors (i.e., public, private HI, OOP) as well as
overall health spending
4. Policy-makers must monitor the effects of
alternative provider payment systems on cost,
access, and quality – MIS is critical
Fundamental Issues
•
•
•
•
•
•
What care will be produced?
How will care be produced?
How much care will be produced?
What level of ‘quality’ will be produced?
To whom will care be offered?
What kinds of care and how much will
consumers ‘demand’/access?
• By what method, how much, and by whom
will providers be paid and/or consumers
reimbursed?
Source: Modified from Rena Eichler, WB, 2003
Incentives To Providers
Depend On How They Are Paid
•
•
Unit of payment:
– individual service
– per visit/encounter
– per day
– per admission
– per episode of illness
– all (or a defined set of services) for a provider for a fixed period of time (i.e.,
salary or global budget)
– all (or a defined set of) services for an individual for a fixed period of time (i.e. full
or partial capitation)
Level of payment
– providers costs
– providers charges
– administratively set by payor
– negotiated
– competitive bidding
Need To Monitor
• Costs
• Quality
• Access
• Impacts across different provider types
• Impacts across all public and private payors
including those paying out of pocket
Basic Principles of P4P
•
•
•
•
•
•
•
•
•
•
•
Increase efficiency in the provision of existing levels of
activity
Where needed, encourage expansion of activity
Enhance patient choice
Increase patient satisfaction
Encourage providers to be responsive to patient and
commissioner preferences
Keep costs under control
Channel funding where it is most needed
Introduce fairness and transparency in funding providers
Encourage the development of new, cost-effective
treatment pathways
Shift patterns of service provision away from historical
patterns
Improve quality
Source: Moraldo, Goddard, and Smith, York CHE Research Paper 19, 2006. Authors use the term PbR – pay by results
Difficult to Control Spending Without a
Single Set of Payment Rules
DELIVERY
SYSTEM
PUBLIC FACILITIES
AND PHYSICIANS
PRIVATE FACILITIES
AND PHYSICIANS
BUDGET
FEE SCHEDULES
CHARGES
SOURCES OF
INSURANCE
COVERAGE
PUBLIC
PRIVATE
UNINSURED
Provider Payment Systems are One of Many
Approaches for Improving Efficiency
Supply side approaches
Demand side approaches
Indirect mechanisms
•
Changing behavior via reimbursement mechanism
•
Changing market structure and behavior by
changing overall ownership (e.g., privatization of
hospitals and facilities)
•
Using global budgets, possibly in combination with
other efficiency targets (e.g., staffing)
Indirect mechanisms
•
Employing payment incentives to encourage
treatment of patients in primary or ambulatory care
•
Introducing user charges and co-payments
Changing care delivery
•
Adopting treatment protocols
•
Introducing performance management (e.g., setting
targets for length of stay, promoting day surgery)
•
Implementing business process reengineering
•
Adapting cost-reduction and efficiency targets
Planning approaches
•
Implementing hospital closure and reconfiguration
programs
Demand management
•
Initiating an appropriateness and utilization review
•
Introducing “evidence-based purchasing”,
specifying explicit rationing of treatments, specifying
a basic package of interventions
•
Developing primary care substitutes
•
Promoting social and domiciliary care
•
Strengthening disease prevention activities
•
Adopting managed care or disease management
Source: M. Henscher
Basic Health Reform Issues
Some Generic Health Reform Priorities
Management,
capacity building,
policy and
planning,
regulation, and
DDM
• Developing capacity by employing multi-disciplinary skilled staff.
• Collecting on a continuous basis necessary data for decision-making (e.g., national health accounts;
epidemiological data to monitor the MDGs, etc.) and monitoring outcomes.
• Coordinating policy-making among multiple public bodies, sectors, and private stakeholders at all
geographic levels.
•Assuring appropriate regulatory frameworks for quality, insurance, system capacity, etc.
Delivery
• Decentralizing management to regional and local levels.
• Assuring appropriate numbers, mix, and geographic distribution of human and physical resources.
• Implementing effective quality assurance systems
• Assuring that overall system capacity corresponds to underlying needs, affordability and efficiency.
• Reform pharmaceutical sector.
Financing
• Assuring access to affordable public and personal health services and provide financial protection by
effective ‘risk pooling’ through public and private financing mechanisms.
• Assuring that such mechanisms (e.g., general revenues, payroll taxes, user charges, premiums) are
equitable (based on ability to pay), efficient (minimize distortions to the economy), simple to administer,
and sustainable.
• Developing, testing, and implementing new methods to pay medical care providers (e.g., global
budgets, capitation, DRGs, etc.) that contain incentives for access, efficiency, and quality for public and
private providers.
Public health
• Better targeting of interventions on the poor and to cost-effective treatment and prevention of
communicable diseases (e.g., ARI, CDD, AIDS, malnutrition) as well as non-communicable diseases and
injuries.
• Implementing effective culturally sensitive reproductive health policies.
• Implementing effective environmental and occupational health policies.
Some ‘Conventional Wisdoms’
About Health Reform
•
•
•
•
•
•
•
•
•
•
It is much easier to expand coverage and benefits than to reduce them
When one creates a uniform universal program from several existing programs, the
benefit package generally ends up being that of the most generous program
One shouldn’t undertake major coverage expansions on an inefficient base system
It is very difficult to finance a reform in the short-term through efficiency gains
Demand side controls are important, but one must keep in mind that cost is often
irrelevant when it comes to peoples’ health and physicians generally determine
demand
Supply side (regulatory and reimbursement) measures are absolutely critical for
controlling costs in any pluralistic, not strictly budget-controlled, system
There are substantial market failures in health that limit the inherent efficiencies
underlying competition either among insurers or providers, requiring complex
regulatory mechanisms for both providers and insurers
Major reforms in delivery arrangements and medical practice take time, particularly if
new types of physician specialists need to be trained
Governments need to consider both private financing and private delivery, given
potential self-referral by public providers, the ability for private insurers and providers
to dump the worst health risks onto the public system, and the opportunity costs of
inefficient private sector investments in terms of lost growth and employment
Rationalization of the health delivery system needs to be an implicit or explicit aspect
of coverage expansions, regulatory, quality assurance, and payment mechanisms
How Can the Financing Gap Be Filled?
• Improve equity and efficiency of current spending in
terms of focusing on cost-effective interventions
targeted to the poor provided through an efficient
health care delivery system
• Undertake appropriate investments in other health–
related sectors
• Improve domestic resource mobilization
• Try to re-allocate private spending for optimal public
purposes including appropriate user charges
• Obtain increased donor support and debt forgiveness
through the adoption of effective macroeconomic and
health sector strategies through PRSPs, MTEFs,
SWAPS, Global Funds, etc.
ODA is Rising But is Far Short of What is Needed to
Meet MDG (0.54) and Monterrey Commitments (0.70)
To meet 2010 commitments (ODA of US$130 billion per year), need an average increase of about 8% per year
Source: OECD DAC database.
Much of the Increase in Aid is Not Directed to
Financing the Incremental Costs of Meeting the MDGs
80
% of net ODA
70
60
50
40
30
20
10
0
1980
1990
Debt Forgiveness Grants
2000
Technical Cooperation
Administrative Costs
Program and Project Aid
Emergency and Food Aid
Source: Sundberg and Gelb 2006.
In 2005, ODA peaked at US$ 106.5 billion -- most of this increase was due to debt relief and exceptional mobilization in
response to the Tsunami and the Kashmir earthquake
ODA is the Main Source of External Finance for SSA, Twice as Large as
FDI and Nearly Four Times the as Large as Remittances
Total long-term
flows of $41 billion
in 2003
Total long-term
flows of $340
billion in 2003
Source: World Bank. Global
Monitoring Report. 2005.
Donor Aid for Health has Increased
Significantly
16
14
US$ billions
12
Private non-profit
10
Other multilaterals
Development banks
8
UN agencies
Bilateral agencies
6
4
2
0
2000
2005
year
Source: Michaud 2007
Where Does All the Aid Go?
On average, for every $1 disbursed by donors to our
14 case study countries, we estimate:
•Not recorded in balance of payment
•Recorded in BOP but not in Govt spending
•Aid earmarked to specific projects
•Budget support
$0.30
$0.20
$0.30
$0.20
•1990s structural adjustment provided a larger share of
aid as general budget resources.
Basic Problems in Current ODA System
• Lack of global governance and policy coherence
• Lack of predictability of funding and large differences between donor
commitments and disbursements at the country level generate
problems of macroeconomic management and planning
• There is a growing concern about the ‘verticalization’ of aid and the
need to focus holistically on health systems as opposed to specific
diseases or interventions
• Large numbers of new actors and donors and the plethora of ‘new’
aid instruments (e.g., SWaps, PRSPs, PRSCs, PRGFs, MTEFs,
etc.) create problems of management and coordination at both the
global and country levels and generate transactions costs and
absorptive capacity constraints
• Lack of responsiveness and flexibility of aid to sudden problems and
crises
• Little accountability of donors for the absence of results and lack of
M&E systems which are needed to ensure that the additional
resources are being used as prioritized and achieving results
• A significant portion of aid is off-budget and often doesn’t even enter
into the balance of payments or the government’s budget
• Countries need to create ‘fiscal space’ to absorb these large
increases in external assistance, a potentially problematic situation
given IMF fiscal ceiling
Donor Commitments for Health are Volatile
and Unpredictable
Try managing this…
Donor Collaboration is a Challenge
GTZ
WHO
CIDA
UNAIDS
RNE
INT NGO
3/5
UNICEF
Norad
WB
Sida
USAID
T-MAP
MOF
UNTG
CF
DAC
GFCCP
PRSP
PEPFAR
GFATM
HSSP
MOH
PMO
MOEC
SWAP
CCM
CTU
NCTP
CCAIDS
NACP
LOCALGVT
CIVIL SOCIETY
PRIVATE SECTOR
Source: WHO: Mbewe
Bilateral Donor Support to Tanzania, 2000-2002
Source: Foreign Policy, Ranking the Rich 2004
Vertical Aid Distorts Priorities
Community
Management
Case
management
Drug
Use
HIV/AIDS
Nutrition
Skilled birth
attendance
New born care
Malaria
PMTCT
Health
system
Source: WHO, Mbewe
Maternal
health
Safe and
Supportive
Environment
Absorptive Capacity Constraints are
Multi-Dimensional
Macro
Macro National
Government
Fiscal
instruments/allocative
mechanisms
Service delivery/ local
government
Institutional
Debt
sustainability.
Monetary and fiscal
policy instruments.
Competitiveness, Dutch
disease.
Exchange rate
management.
Physical and human
Social/cultural/political
Administrative,
Stable national political
management, and planning institutions, power-sharing
skills, trained technicians, mechanisms, social stability.
sector specialists.
PEM (budget
Sector management skills. Cultural norms, weak institutions,
preparation/execution,
power sharing mechanisms
accounting, treasury,
audit, etc.)
Connectivity and
communications networks.
Administrative
capacity.
Legal framework.
Local government
institutions, private
sector capacity.
Road accessibility, water
control, geography. Local
government skills and
capacity.
Cultural norms, ethnic, caste,
class, relations.
Local power structures.
Constraints to Improving Access to Health Interventions
Constraints to Improving Access to Health Interventions
Level of Constraint
I. Community and
Household Level
Type of Constraint
Lack of demand for effective interventions
Amenability of Additional Funds to
Reduce Constraints
High
High
Barriers to use of effective interventions (physical, financial, social)
II. Health Services
Delivery Level
Shortage and distribution of appropriately qualified staff
High
Weak technical guidance, program management and supervision
High
Inadequate drugs and medical supplies
High
High
Lack of equipment and infrastructure, including poor accessibility of health services
III. Health Sector Policy
and Strategic
Management Level
Low
Weak and overly centralized systems for planning and management
Weak drug policies and supply system
Medium
Inadequate regulation of pharmaceutical and private sectors and improper industry
practices
Medium
Lack of intersectoral action and partnership for health between government and civil
society
Low
Low
Weak incentives to use inputs efficiently and respond to user needs and preferences
IV. Public Policies
Cutting Across Sectors
V. Contextual and
Environmental
Characteristics
Reliance on donor funding that reduces flexibility and ownership
Low
Donor practices that damage country policies
Low
Government bureaucracy (civil service rules and remuneration; centralized
management system; civil service reforms)
Low
Poor availability of communication and transport infrastructure
High
Governance and overall policy framework
Low
Corruption, weak government, weak rule of law and enforceability of contracts
Political instability and insecurity
Low priority attached to social sectors
Weak structures for public accountability
Lack of free press
Physical environment
Climatic and geographic predisposition to disease
Physical environment unfavorable to service delivery
Source: Olivera et al 2001
Low
The Face of the HRH Crisis
RECRUITMENT
ATTRITION
Pre-service training
-Clinical vs Managerial
-Specialist vs polyvalent
-Death
-Professional vs volunteer
-Braindrain: loss vs gain
-Pension
Social Franchising
DISTRIBUTION
-Geo: rural vs urban
RETENTION
-Monetary: salary vs allowances
-Level: central vs service delivery
-Secondary: housing, transport,
communication, electrification, child
education, training opportunities etc.
-Sector: public vs private
-HR management
-Type: key-staff vs others
What Will Donors Have to Do?
• Harmonize procedures (procurement,
financial mgt, monitoring & reporting) in order
to improve impacts and reduce donor and
country transactions costs
• Provide increased and predictable long term
financing
• Finance recurrent costs
• Offer consistent policy advice
• Submit to common assessment of their own
performance
What Does This Mean for Countries?
•
•
•
•
•
•
•
•
Develop credible strategies and plans to foster economic growth, deal with
implementation bottlenecks, and reach MDGs as part of PRSPs, SWAPs,
MTEFs, and public expenditure programs
Improve governance including giving voice to communities, consumers and
openness to NGOs and private sector
Enhance absorptive capacity through decentralization, efficient targeting
mechanisms, and institutional reforms including having a clear fiduciary
architecture and open reporting of results
Improve equity and efficiency of resource mobilization and commit resources
Middle income countries need to make the commitment to develop and
implement effective health reform strategies relying on evidence-based policy,
best international practice, and MDG+ goals and indicators
Develop financing, management, and regulatory mechanisms for equitable and
effective pooling of insurable health risks as a necessary concomitant to MDG
and CMH intervention choices.
Integrating vertical programs into a well functioning health system to maximize
health-specific and cross-sectoral outcomes and reduce transactions costs
Monitor and evaluate results
A Shared Global Approach
• Build on existing funding modalities
• Use and further improve existing plans and
mechanisms at the country level
• Address inequities within countries
• Scale up cost-effective interventions
• Tackle critical implementation constraints
• Apply a multi-sectoral approach
• Focus on results
• Country orientation, but global action is also
needed
The Basic Instruments
Public Expenditure Management Instruments
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Poverty Reduction Strategy Paper (PRSP) – a comprehensive, long-term,
country owned, participatorally developed, results-oriented plan focused on
poverty outcomes and the multidimensional nature of poverty
Medium Term Expenditure Framework (MTEF) – a fiscal framework that
consists of a top down resource envelop, a bottom-up estimate of the
current and medium term costs of existing policies and, ultimately, the
matching of these costs with available resources in the context of the
annual budget process
Sector Wide Approach (SWap) -- a health policy and donor coordination
mechanism designed to be country-driven; based on a shared vision of a
comprehensive sector development strategy that reflects all development
activities including identification of gaps, overlaps, and inconsistencies;
establishes agreed upon priorities for the sector; contains an expenditure
framework that clarifies sectoral priorities and guides all sectoral financing
and investment; and, creates partnerships across development assistance
agencies that reduce governments’ transaction costs
Public Expenditure Review (PER) – a comprehensive analysis of the
levels and composition of government spending and revenues that
assesses inter- and intra-sectoral allocations, public enterprises, the
structure of governance, and the functions of public institutions
Public Expenditure Tracking Surveys (PETs) – surveys that track the flow
of publicly funded services through the layers of bureaucracy down to the
service facility that is charged with responsibility for spending