1. Public Expenditure Tracking Surveys and the measurement of corruption Lessons from experiences in the health sector Presentation by Magnus Lindelow (EASHD) WB Governance and anti-corruption course February, 2006

2. Tracking surveys—where it all started The ‘emblematic’ PETS—education sector in Uganda (1996) GOU had increased in spending on primary education, but seen little impact on enrollment PETS collected data from 250 schools Only 13 percent of intended capitation grant actually reached schools (1991-95) Government responded with information campaign and other measures Survey coincided with trend towards budget- or sector-support  stimulated PETS in other countries A story less told but equally relevant: the 1996 health PETS in Uganda Failed due to lack of poor or absent records, unclear allocation rules, etc. Many PETS have fallen somewhere in-between these two exercises

3. Tracking surveys—recent experiences Since Uganda PETS, similar surveys have been undertaken in large number of countries, across regions GCR chapter summarizes 12 surveys from 10 countries Motivating question for most PETS Do resources allocated to health or education actually reach the facilities or schools that are supposed to deliver services? Focus has varied Overall budget allocation Specific resource flows (drugs, etc.) Personnel Approach Collect information on allocation of budgets, material (drugs, school books, etc.), personnel, etc. Collect data from health facilities or schools on what resources are actually received Compare and estimate ‘leakage’

4. Sounds like a good idea, but… What if there are no explicit allocations? There are often no explicit budget allocations or allocation rules to individual facilities Even if there are, local administrators often have a lot of discretion to change during year If facilities or schools receive less funds than they are supposed to, is it necessarily an indication of corruption? There may be delays in budget execution or distribution system due to capacity weaknesses, red tape, etc. Resources may be re-allocated for legitimate reasons Can we trust the data? Financial and other records are often poorly kept Difficult to find enumerators with the necessary skills and motivation to collect quality data  It has often proven difficult to reach firm conclusions on leakage

5. Findings from PETS in the health sector Some surveys have found evidence of leakage Facilities receiving less budgets than intended Ghost workers Absenteeism See GCR chapter for summary Other findings from surveys also important Problems in budget execution process—delays, lack of transparency, etc. Poor record keeping—could reflect capacity weaknesses, outdated systems and heavy administrative burdens, information not used, ‘gaming’ to conceal corruption Weaknesses in control and accountability mechanisms Inequalities in the allocation of resources Availability of resources at facility level—lack of equipment, drugs, other supplies, etc.

6. An illustration from Mozambique Expenditure Tracking and Service Delivery Survey undertaken in 2002 Linked to PER and Health Sector Expenditure Review and implemented as part of capacity building and institutional support project (DfID) with the Ministry of Planning and Finance Data collected through interviews and record reviews all 11 provinces 35 randomly selected district health offices 90 randomly selected primary level government facilities 180 randomly selected health workers 680 randomly selected clients Survey followed by joint MOPF/MOH regional dissemination events to present findings and discuss policy options

7. Non-wage recurrent budget Drugs, vaccines, and medical supplies Personnel / salaries Allocation rules Legally binding allocations to provinces; explicit but changeable allocations to districts, no financial flows to facilities Nominally allocated on basis of facility activity, but considerable local discretion Provincial allocations determined centrally; considerable discretion within provinces Source of data Financial statements at provincial and district level Distribution and stock records at different levels Personnel records at province, district, and facility level LeakageDiscrepancies b/w province & districts for 75% of districts, but not systematic Some drugs ‘sent’ were not ‘received’, but much noise Inconsistencies in data across levels, but not systematic; 18% of facility staff were absent Other findings - Poor record keeping (complete records for only 40% of districts) - Delays (>)> - Low district level execution (40% in some districts; 80% average) - Inequalities (>)> - Delays/stock-outs - Non-kit supply of drugs more important than anticipated - Large disparities in drugs distributed to facilities per outpatient (e.g. aspirin between 1.1 and 16.8 - Delays in salary payments (60% receive salaries late ‘often’ or ‘almost always’) - Dissatisfaction, in particular in rural areas (75% of staff in rural facilities wanted to transfer) Non-medical supplies (fuel, food, etc.): procured by district health offices and distributed to facilities on discretionary basis--not amenable to tracking User fees: variation in fee regimes (despite national policy); some facility revenues ‘ unrecorded’

8. Limitations of PETS PETS have mainly been applied in ‘public integrated’ systems—i.e. government finances and operates facilities Tool may be less applicable in insurance based systems PETS focus on narrow question—getting resources to facilities is only half the battle Takes allocation as given, but is allocation appropriate (equity, efficiency)? Do arrangements for financing, organizing, and regulating of service providers promote efficiency and quality? What about the private sector? PETS can be powerful diagnostic tool, but why do problems arise and how can they be fixed? PETS can provide some insight, but other approaches also needed PETS can be used to evaluate impact of interventions (e.g. Uganda education)

9. So, what does this mean if you are thinking about doing a PETS? Is PETS the right tool? What are the issues / information gaps? Health system characteristics? Data quality?—reliability of administrative records, capacity of local survey organizations Are PETS findings likely to have an impact? Start small Small scale pilot with qualitative component can generate better understanding of system and issues and generate buy-in Stay small? PETS can be expensive. Is it worth it? Trade-off between scale and data quality—e.g. university students vs. qualified accountants as enumerators Is there a process for finding solutions? Diagnostic work can be inflammatory—e.g. absenteeism Response typically requires engagement on sector-specific issues, as well as broader PEM issues

10. Delays in the first budget transfer to district health offices Back

11. Inequalities in district level government health spending