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Budgets in Africa
Health and PFM

Health Budget Report

Welcome to the CABRI Database on Public Health Budget Practices and Procedures in Africa. This data shows the results of a survey in Africa, involving 15 countries released in 2020. The survey aimed to provide African officials with information on budget processes within different countries as a point of reference for the implementation of budget reform.

The 15 participating countries which diligently completed the survey and whose invaluable insights informed this report are: Benin, Cameroon, Chad, Côte d'Ivoire, the Democratic Republic of the Congo, The Gambia, Guinea-Bissau, Lesotho, Liberia, Mauritius, Nigeria, the Seychelles, Sierra Leone, South Africa, and Uganda.

The survey was intended as an instrument to help governments learn from each other and understand the potential gaps and ways in which to address the challenges they face in health budgeting and execution processes. While no two contexts are the same, there is space for officials from different African governments to scrutinise other countries facing comparable problems and consider applying successful solutions in their respective countries.

The data provides, inter alia, information on the following key elements:
    • Budget allocations for the health sector
    • The role of institutions in budgeting for health
    • Performance-based budgeting
    • Purchasing and provider payment systems
    • The management of development assistance for health
    • The role of the ministries of health in the water, sanitation, and hygiene activities (WASH)

    The survey results revealed the following trends in budget practices:

    • Ministries of finance set budget envelopes while ministries of health decide how resources are spent. In most countries, a formal coordinating mechanism for the health budget and the prevention of specific diseases exists.
    • All countries surveyed except for Guinea-Bissau use medium-term expenditure frameworks (MTEFs) though they are used differently across states, and all countries make a distinction between operating and capital expenditure.
    • A key challenge faced by ministries of finance in monitoring budget execution, is the time within which expenditure data becomes available. The data suggest that underspending seems to be a larger issue than overspending.
    • Operational issues within the ministries of health are identified as the leading cause of underspending, though the slow release of funds from ministries of Finance also appears to be a contributing factor.
    • Most donor spending is not channelled through the regular public finance management process, although all countries track donor health spending via a coordinating body. Development partners often implement projects through their staff, internal and financial systems, and separate monitoring and evaluation systems.
    • Ministries of health have no role in the provision of bulk water supplies, but they are actively involved in promoting hygiene. WASH activities are funded through central government revenues with donor support.
    • In most countries, the central government is the chief provider of primary and preventative health services. Only Benin, Côte d'Ivoire, and Nigeria use a social insurance mechanism.
    • Eight countries use a tender process to acquire drugs.

    The findings imply a need for ministries of finance and health to work more closely together to achieve an efficient use of resources in Africa. Similarly, better coordination between the ministries of health and donors on budgeting and execution processes is likely to enhance resource use. Finally, ministries of health are likely to benefit from regular engagements with departments or institutions responsible for developing infrastructure and water supplies, on which the effectiveness of hygiene and sanitation programmes are highly dependent.

    Income inequality (Gini coefficient)

    GDP (per capita 2018, PPP constant US$)

    Life expectancy (years)

    Population (m)

    Health budget formulation

    Are health expenditures included in the central government budget?

    Institutional responsibilities in budgeting for health – overall levels of healthcare

    Institutional responsibilities in budgeting for health – capital and coverage

    Institutional responsibilities in budgeting for health – payments and wages

    Mechanisms for budgeting for health

    Institutional structure of healthcare budgeting

    Budget processes

    Budget processes: medium-term allocations

    Do the budgeting process and budget documents specify budget allocation by healthcare functions?
    If Yes: are all public health expenditures included under the ceilings of the medium-term framework?

    Does your country have a medium term fiscal and/or expenditure framework?
    If yes:

    Do the budgeting process and budget documents specify budget allocation to specific diseases?
    If yes:

    Do the budgeting process and budget documents specify budget allocation to individual health facilities?
    If yes:

    Budget process – other allocations and distinction between capital and operating expenditure

    Performance-based budgeting

    Budget process – protection from cuts, and performance-based budgeting

    Institutional structure of health purchasers

    Main providers of acute inpatient services

    Main providers of preventive services

    Main providers of primary care services

    Main providers of specialist care and diagnostics

    Main providers of pharmaceuticals

    Main providers of public health

    Provider payment systems

    Provision of healthcare through health insurance

    Main type of payment systems in surveyed countries

    Use of caps on payments to providers

    Procurement practices for pharmaceuticals

    Procurement of pharmaceuticals dispensed in hospitals

    Procurement of pharmaceuticals dispensed in the community

    Practices to determine pharmaceutical prices

    Mechanisms for monitoring expenditure

    Responsibility for monitoring budget execution

    Data availability for monitoring purposes

    Budget execution

    Reasons behind underspending

    Performance agreements and assessments

    Performance agreements – who decides on indicators?

    Consequences of not achieving performance indicators

    Use of spending reviews and other mechanisms to cut or expand spending

    Figure 16: Government awareness of development assistance for health (DAH) funds and projects

    Summary of DAH coordination mechanisms by country

    Management process for use of development assistance

    Establishment of additional structures for programmes and projects

    Location of development assistance management function

    Frequent content in aid management policies

    Role of ministries of health in WASH activities

    Role of Ministry of Health in Water, Sanitation and Hygiene (WASH) activities

    Role of Ministry of Health in WASH activities, water and hygiene

    Role of Ministry of Health in matters related to hygiene

    Coordination of WASH activities

    Financing of WASH activities

    Monitoring of WASH activities and coordination with donors

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