Despite an extensive health infrastructure, provincial health indicators are still far behind the MDG targets. In SNG districts PKR 4 billion were spent on primary healthcare provision in 2013-14. However, around 70 per cent of the population in KP uses private health care facilities due to the lack of operational public facilities and their poor quality. According to the World Bank (2013) the utilization rate of the BHUs in KP is the lowest in the country.
In response to the above-stated situation, SNG carried out a rapid public expenditure tracking exercise across a sample of health facilities in Khyber Pakhtunkhwa. The study took a random sample of BHUs in two SNG focus districts, i.e. Buner and Karak.
SNG key interventions to promote facility-based expenditure tracking system are listed below:
- Citizen engagement: Through the establishment of Primary Health Care Management Committees (PCMCs) and Health Management Boards (HMBs) in all districts. The HMBs have been constituted for 21 District Headquarter (DHQ) Hospitals and 26 Tehsil Headquarter (THQ) Hospitals in six SNG focus districts. The composition of PCMCs, roles and responsibilities and fund management arrangements are being finalised. These committees are mandated to provide input in facility level planning, budgeting, community outreach, and oversight of service delivery.
- Needs based budgets: The aggregate budgeting practices were replaced by facility based budgets and captured within IFMIS. Needs based budgeting for primary healthcare facilities was piloted for two districts, i.e. Haripur and D.I.Khan in 2016-17, resulting in 22% increase in allocation for non-salary expenditures and over 90% utilisation. In 2017-18 facility-based budgets were prepared for 219 facilities in six SNG Districts and approved by the District Councils, resulting in an increase of 41% in total expenditure allocation. Improved budgeting practices included planning for purchase of drugs and medicines which make up 23% of non-salary budget in these districts.
- HR rationalization: A reconciliation of databases at provincial and district level for sanctioned posts and payroll had not been undertaken for the past several years. This had resulted in anomalies in sanctioned posts for each facility, staffing criteria, and vacant posts that had not been filled. A comprehensive HR reconciliation exercise was undertaken to address these anomalies and as a result 3,423 posts were reconciled. The identification of these anomalies in other findings of the exercise led to the launch of a more comprehensive and extensive analysis of existing HR strength vis-à-vis the staffing criteria of minimum health service delivery package. The exercise was conducted in Mardan district with the support of TRF+ and in six SNG focus districts.
- Expenditure tracking: Automated expenditure tracking against facility based budgets was enabled through the IFMIS. Each facility was assigned a unique identifying code, i.e. a drawing and disbursing code and budgets have been uploaded in the system against which budget execution reports can be generated. The expenditure tracking system was piloted in two districts in 2016-17. Based on the analysis of the pilot a decision was taken to modify system design and pilot improvements in Karak for both health and education sectors.
- Guidelines for rollout: These guidelines were developed for District Health Officers to facilitate sustainability and continuity of the facility level budgeting and expenditure tracking system. Orientation sessions were conducted for the newly hired staff of Financial Management Cell in Health Department and the DHOs of 25 districts. In addition, formal training session was held in Provincial Health Services Academy (PHSA) for 30 officers.
- Replication in other sectors: Based on the encouraging results of the pilot test in health sector, the Finance Department and Additional Chief Secretary recommended the system to be replicated for primary schools and police stations. The system was replicated in education sector in district Karak during FY2017-18 with support from KESP, which has led to identification of ghost teachers within the E&SE Department.