Research and policy development led by Prof. Peter Berman focuses on how to improve health program performance through better health financing policies and practices in low and middle-income countries. The team developed and applied a “Resource Tracking and Management” (RTM) framework. The RTM framework provides an end-to-end health financing analysis by tracking resources, identifying bottlenecks, and applying policy solutions along 5 key steps of the flow of funds for health programs linked to key objectives. “Resources” include financing as well as physical inputs, such drugs and supplies and human resources.
Resource Tracking and Management Framework
The expandable tables below provide an orientation to each component of the RTM framework, as well as details about the ongoing work related to that area of the framework.
What are the determinants of total resource envelope for health at national and sub-national levels?
Resource mobilization refers to the means or mechanisms to generate resources, at the national and sub-national levels, to pay for goods and services used to deliver health care in a country. Health financing mechanisms used to generate health resources may include general government revenue, earmarked taxes for health, social health insurance, private health insurance, external aid, user fees (out-of-pocket spending at point of care) and other community contributions.
Key Tools/Methods: Fiscal space analysis
How are funds allocated to different programs and functions at national and sub-national levels? What factors determine the allocation to primary care?
Key Tools/Methods: Public Expenditure Reviews (PERs), Cost-effectiveness analysis and priority setting, planning/budget process, and National Health Accounts (NHAs)
Are the allocated funds being utilized? What factors drive successful budget execution? What are the existing bottlenecks?
Key Tools/Methods: Public Expenditure Tracking Surveys (PETs), analysis of public financial management design, governance, and capabilities
How effectively are resources being translated into services? What are the effects on volume and quality?
Key Tools/Methods: Quantitative Service Delivery Survey (QSDS) or facility surveys, analysis of technical efficiency in service delivery (e.g. cost analysis, DEA/FPF analysis), assessment of efficiency/quality linkages
Are inputs benefiting the intended individuals and population? Is public spending reaching the poor?
Key Tools/Methods: Benefit Incidence Analysis (BIA)
Resource Mobilization: Ethiopia is committed to advancing rapidly towards universal health coverage through scaling up primary healthcare investments while decreasing out of pocket spending. Increased resources for health are needed to achieve this goal and evidence-based resource mobilization can support raising the resources required. Ethiopia’s 1998 Health Care and Financing Strategy (HCFS) (link) articulated this need and was successfully implemented for more than 15 years. A new strategy, necessitated by changes in the health system architecture and increased resource needs is currently pending cabinet approval. Our work supported the Federal Ministry of Health (FMOH) in the revision process, beginning with reviewing resource mobilization results since the endorsement of the HCFS (link). Complementing this work, a financial projection model was developed (link) presenting resource availability with possible financing scenarios and projected resource needs for primary care through 2035; aligned with the Federal Ministry of Health (FMOH)’s vision for universal health coverage (link). We continue to support the FMOH to transition towards increased domestic resource mobilization in the revised National Health Financing Strategy (NHFS) (link) and in the 5-year Health Sector Transformation Plan (HSTP) (link).
Resource Allocation: In addition to generating evidence for effective resource mobilization, the financing projection model (link) also analyzed resource allocation at federal, regional and woreda levels, analyzing the share of total and government health expenditure allocated to primary health care across Ethiopia’s different government financing channels. Our team has also supported the FMOH in implementing the 2016 national household health care utilization and expenditure survey for the sixth national health accounts analysis (link when ready).
Also contributing to evidence on resource allocation is a primary health care costing study which analyzed service delivery costs at 24 primary hospitals, 47 health centers and 22 health posts representing different regions around Ethiopia. Unit costs for specific services and departments such as outpatient, inpatient, MCH, and delivery services were calculated, disaggregated by ‘drugs and supplies’, ‘human resources’ and ‘indirect costs’. The study reports the shares of total spending on these facilities allocated to different types of services and inputs (link to report). Findings include estimates of differentials in spending across urban and rural regions of Ethiopia, a significant share of primary care spending being appropriately allocated to drugs and supplies, and evidence on variation in the productivity of health workers in primary level facilities.
Findings from the costing study are being used by FMOH to estimate the fiscal impact of expanding the exempted services package (services that are provided free to all patients in public facilities), develop tools to improve budgeting and planning at woreda and regional levels, and to develop strategies to achieve greater efficiency in service delivery – one of the core objectives of the HSTP.
Another study relevant to resource allocation was a report (link) on strengthening public-private partnerships (PPP) for better health outcomes in Ethiopia. The report reviews the PPP experiences in Ethiopia and globally, recommending devising clear standard operating procedures to manage PPPs, introducing cost-sharing, establishing PPP units at central and district levels and harmonizing the multitude of different contractual schemes that currently exist. Various modalities are proposed as being more effective, such as private provision of selected advanced diagnostic and treatment services, as well as the outsourcing of both clinical and non-clinical services. The report on public private partnerships can be accessed here (link).
Resource Utilization: Ethiopian data was analyzed to quantify the utilization of the government budget. This evidence could be used to improve resource use. For example our findings showed that the recurrent budget (e.g. salaries, drugs, medical supplies, facility running costs) was utilized at a rate that was above 95% for the past six years, while the capital (e.g. infrastructure, capital medical equipment procurement) budget was utilized at a lower average rate of 75%, pointing out to potential capacity and efficiency issues. Budget utilization also varied across primary health care facilities between 51% to 104%.
Resource Productivity: The PHC costing study (described above under “resource allocation”) quantified the unit costs for facilities as well as specific categories of services. Using the results of the PHC costing, our team worked with the FMOH to analyze the efficiency of resource use at the facility level. The efficiency study (link) found that the per capita costs at health centers were relatively high compared to primary hospitals, potentially due to low utilization or high staffing relative to utilization. While not controlling for quality of care, the study found that if the most inefficient facilities (defined as having high expenditures given volume) became as efficient as the most efficient facilities in the sample, there would be input savings of up to 6.4 million birr in human resources, 1.4 million birr in drugs, and 4 million birr in indirect costs. Overall, the study found that there is a significant correlation between financial and physical resource inputs and outputs with regards to the level of efficient production.
Other work on resource productivity in Ethiopia looked into how health extension workers use their time and what the biggest challenges were for health extension workers in both rural and urban areas (link). The study showed that most of a health extension worker’s time goes to ‘waiting for clients in the health post’ (29%) and ‘travel between work activities’ (16%), while only 14% of HEWs time is spent ‘providing health education or services’. Of the services provided, 45% were ‘family health’ services, and 30% were ‘hygiene and sanitation’ services. The study further found that the main motivating factor for HEWs is ‘pride of serving the community and seeing positive change’ while the main demotivating factors for the health extension workers were related to professional career growth moving slowly, inadequate in-service refresher training, and financial limitations, both personal and institutional. The full time-motion study report can be found here (link).
Resource Targeting: As part of the HCFS review (link), an assessment was done to analyze the targeting of the fee waiver program, which found the program to be performing poorly except in Amhara region.
Our team is currently working closely with a team at the Financing and Resource Mobilization Directorate, FMOH to develop a benefit-incidence analysis combining evidence from household surveys, public expenditure analysis in Ethiopia’s NHAs, and costing study results. This will describe the degree to which public spending is reaching the poor. Adapting different methods, we hope to be able to trace changes in targeting of public spending on health to the poor from the mid-2000s to the present. Results should be available in the second half of 2017.
Resource Mobilization: The Indian government set a goal in 2005 of government health spending to be between 2-3% of gross domestic product (GDP) by 2012. Since the mid-2000s, high political commitment to the health sector led to an increase in government spending, but still falling short of the goal with only 1% of GDP by 2010/11. Since then, a restructure of the health sector arena occurred with a change of responsibilities and role for the National Health Mission (NHM). The Harvard Chan School worked with the Ministry of Health and Family Welfare (MOHFW) to conduct a national and sub-national health expenditure analysis for more up-to-date evidence on government health spending, developing a state-level database on total government health spending and government spending on primary health care. The results indicated that the ambitious goals of 2005 were still not attained by 2015 and explored reasons for the shortfall, including those related to public financial management. Additional analysis identified that central government funding was associated with reduced state-sourced funding in a number of states. See report and presentation, as well as National Health Sector Expenditure Analysis for 29 states presentation.
Resource Allocation:National-level government expenditure data was used to estimate shares of government spending to primary health care, using an MOHFW methodology. Detailed case studies in Uttar Pradesh and Bihar were carried out on district and block level locations to identify the shares spent on human resources, drugs and supplies, and establishment costs. Drugs and supplies expenditures were very low.
Resource Utilization:The Uttar Pradesh and Bihar case studies explored gaps between budgeted funds and actual expenditures and identified a number of factors in the operation of state-level societies and treasury funds that explained a large shortfall. Comparative case studies in three states with better resource utilization, Kerala, Maharashtra, and Rajasthan, identified factors at state level that could improve resources utilization.
Resource Productivity:In the Uttar Pradesh case study, analysis at block level identified only a weak association between resource inputs such as staff and funds for operating costs, and service outputs. This suggests that operational issues may be very important determinants of the effective use of funds. See presentation.
Resource Targeting: National data on government expenditures and health care utilization were combined to estimate the distribution of the financial value of government services consumed according to income groups – a benefit incidence analysis. While overall, the distribution of government spending was fairly neutral to income levels, there was a high degree of inter-state variability. See presentation .
The Resource Tracking and Management in India and Ethiopia project (RTM) was awarded to HSPH (PI Peter Berman) by the Bill & Melinda Gates Foundation in 2013, and will complete implementation mid-2017. RTM is working in Ethiopia and India to enhance efficiency, effectiveness and equity in primary care delivery by regularly applying financial resource tracking and management (RTM) methods. Additional health financing and health economics analytic work and capacity development for Ethiopian government staff is being supported by the Fenot: Achieving Excellence in Primary Care project, also generously funded by the Bill & Melinda Gates Foundation (PI Peter Berman), with implementation continuing through 2019.