Ghana and Bangladesh Share Promising Practices for Health Budget Accountability

A child receives care at a health screening in Bangladesh. (Photo: Maggie Moore/USAID)

By Heather Viola

The LHSS-JLN Health Budget Execution Learning Exchange is a forum for eight countries[1] to identify and share promising practices for ministries of health to improve health budget execution while national efforts to strengthen general PFM systems are ongoing. The countries first created a shared vision of “good” health budget execution and then agreed on four crucial enabling factors for achieving that vision. One of those crucial factors was the budget structure and process, for which promising practices were described in the previous blog, Lessons from Three Countries That Have Strengthened Budget Structures and Processes to Improve Health Budget Execution. The second, and arguably the linchpin for all, is accountability.

Defining Accountability

Participants in the Health Budget Execution Learning Exchange — an initiative led by the USAID Local Health System Sustainability Project (LHSS) in collaboration with the Joint Learning Network for Universal Health Coverage (JLN) — agreed that accountability in the context of health budget execution includes four essential components (Figure 1):

  1. At the time of priority setting and budget formulation, expectations and goals are clearly defined for both financial management (e.g., amount and proportion of funds spent by each program) and program management (e.g., service delivery targets and health outcomes).
  2. Processes exist to integrate relevant and diverse stakeholders (e.g., Ministry of Health, Ministry of Finance, Ministry of Planning) into priority-setting and budget formulation discussions.
  3. IT infrastructure sufficiently tracks adherence to expectations set across health and PFM domains. This analysis ideally enables monitoring of health spending against both health priorities and PFM objectives.
  4. Consequences for not following defined expectations are well communicated and understood (e.g., reprioritization of misused or unspent funding).

Accountability, as the participants defined it, requires the three other enabling factors identified during this learning exchange: Legal frameworks determine responsibility for critical roles in budget execution; priority-setting processes help set clear expectations and objectives for budget execution and ensure value despite constrained resources; and budget structure and processes define how the flow of funds is operationalized throughout the system. Accountability mechanisms support monitoring and reporting of health budget execution and are dependent on the efficient functioning of the other three enabling factors.

Figure 1. Accountability for “Good” Health Budget Execution

Accountability Approaches in Ghana and Bangladesh

During the Learning Exchange, Ghana and Bangladesh shared their experiences in implementing budget accountability mechanisms.

To improve accountability for health budget formulation and execution, Ghana developed two new systems: the Planning and Budgeting Management Information System (PBMIS) and the Ghana Integrated Financial Management Information System (GIFMIS). With these, Ghana successfully integrated health data systems with financial management data systems to facilitate better monitoring of performance trends, budget planning, and budget advocacy for specific health priorities.

The PBMIS has improved linkages between policy, planning, resource allocation, and performance outcomes, promoted efficient resource allocation by disease burden, reduced work to prepare and submit budgets (e.g. consolidation of budgets in real-time), and provided new functionalities and tools to view budgets in real-time within the Ghana Health Service. This includes dashboards that present budgets by policy objectives, funding source, and disease burden for use at the Ghana Health Service.

A key takeaway from Ghana’s experience was the importance of engaging a broad range of stakeholders across health program areas as well as representatives from planning and budgeting units in designing and implementing new data tools to ensure that information systems are tailored to the needs of the stakeholders that will use it. Ghana also stressed the value of developing local capacity to ensure sustainability of tool implementation, starting with small tools that are easily available (e.g., MS Excel), and iteratively applying more sophisticated software, such as those with more online, automated, or integrated functionalities, as capacity and resources increase.

Bangladesh shared their experience introducing the Integrated Budget and Accounting System (IBAS++) and implementing Annual Performance Agreements (APAs). IBAS++ is a decentralized, automated system to support budget formulation, execution, and monitoring, and to track the implementation of government priorities. APAs are a results-oriented performance evaluation system that entails an agreement between a minister representing the people’s mandate and the agency responsible for implementing the mandate. APAs are used as a mechanism to first establish priorities and objectives, and then communicate and align on these priorities. APA implementation helped Bangladesh transition mindsets towards a culture of accountability and transparency linked to the achievement of results rather than simply implementing required processes.

The Bangladesh approach paired a communications tool with a measurement tool, linking the communication of health priorities with the system, tools, and capacity to measure and track those priorities. Both the APAs and IBAS++ have been observed to improve quarterly monitoring and evaluation of health budgets, improve the timeliness of health budget transfers and utilization, and improve government capacity to effectively decentralize fiscal responsibility by enabling sub-district to use these systems. These innovations have fostered a culture of greater accountability for improved health budget execution.

Key Lessons for Improving Budget Accountability

Ghana’s and Bangladesh’s experiences offer practical lessons that other countries can adapt to their own budget execution needs. While their approaches and contexts differ, two key learnings emerged.

Mechanisms or systems that improve communication of priorities and enable improved monitoring and evaluation of budgets lead to greater accountability. This can include communication and coordination across different administrative levels, across line ministries, or between executive and legislative authorities. For example, in Bangladesh, the use of APAs has improved communication and alignment towards accountability.

Interoperable health data and public financial management systems are critical to realize improvements in health budget execution. As information systems and budget processes become more transparent and sophisticated through government-wide public financial management reforms, countries have made deliberate efforts to ensure interoperability of health data with non-health (e.g., finance, demographic) data to achieve better alignment between budgets and health priorities. These more sophisticated, data-driven accountability mechanisms have the potential to enhance data analytics, improve efficiencies (e.g., submission of budgets remotely and in real-time through GIFMIS and PBMIS in Ghana) and increase transparency and reliability within budget execution (e.g., greater visibility of spending and performance of health programs). These measures ensure the execution of health budgets in alignment with the health priorities identified during priority setting.

Next up…

Stay tuned for the final blog in this series, a summary of key learnings from the Health Budget Execution Learning Exchange that can help interested countries move from an inhibiting to an enabling environment for better health budget execution and, ultimately, improve access to high-quality health services for their populations.

Notes:

[1] Eight countries participated in the learning exchange: Bangladesh, Ghana, Kenya, Lao PDR, Liberia, Malaysia, Nigeria, and Peru.

About the author:

Heather Viola is a program officer at R4D and manages the LHSS-JLN Health Budget Execution Learning Exchange.

Additional contributors:

Cheryl Cashin is a managing director at R4D and the lead author of the joint R4D-WHO publication, Aligning Public Financial Management and Health Financing.

Miriam Omolo is a health financing expert and country facilitator for LHSS-JLN Health Budget Execution Learning Exchange. She also serves as Executive Director at The African Policy Research Institute.

Aparna Kollipara is a health financing expert and a member of the technical facilitation team for the LHSS-JLN Health Budget Execution Learning Exchange.

Nivetha Kannan is a program associate at R4D and a member of the technical facilitation team for the LHSS-JLN Health Budget Execution Learning Exchange.

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LHSS Project

LHSS Project

USAID’s Local Health System Sustainability Project helps countries achieve sustainable, self-financed health systems that offer quality health care for all.