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Assessment of the Financial Flows in Mozambique

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Assessment of the Financial Flows in Mozambique Assessment of the Financial Flows in Mozambique June, 2016 VillageReach is a global health innovator that develops, tests, implements and scales new solutions to critical health system challenges in low-resource environments, with an emphasis on strengthening the “last mile” of healthcare delivery. www.villagereach.org // [email protected] Page 2 Table of Contents Executive Summary ....................................................................................................................................... 3 Background ................................................................................................................................................... 3 Methods ........................................................................................................................................................ 4 Results ........................................................................................................................................................... 5 3.1 Planning process .................................................................................................................................. 5 3.2 Financial flow ....................................................................................................................................... 8 3.3 Gavi funding ...................................................................................................................................... 11 3.4 Challenges that have affected the EPI ............................................................................................... 13 Discussion and Recommendations .............................................................................................................. 14 Annex .......................................................................................................................................................... 17 List of people interviewed ....................................................................................................................... 17 Quantitative questionnaires .................................................................................................................... 18 Qualitative questionnaires ...................................................................................................................... 18 Page 3 Executive Summary VillageReach conducted a study to identify financial flow bottlenecks negatively impacting Mozambique’s vaccine program (Programa Alargado de Imunização or PAV) at each level of the health system. The study aimed to identify the causes of delays and strategies to improve the financial flow for a more efficient financial management and improved supply chain functioning for routine immunization. Working together with UNICEF, the study used a rapid assessment tool that was developed and first piloted by UNICEF in Uganda, by adapting it to the Mozambique context. The purpose of this tool is to quickly assess areas of financial flow at each administrative level of the government and identify potential solutions to financial flow issues. Main challenges identified through the study include the following: EPI programs are not always fully implemented as planned, mainly due to limited funding and delayed availability of funds, however it has never completely stopped operations due to lack of funding. Districts and health facilities also indicated not knowing what resources are available to the program. Recommendations for improving the financial flow include: Improve the planning process Improve monitoring of core immunization service activities and expenses Build capacity for financial management Background An immunization supply chain ensures that vaccines and related supplies are available at their intended point of use. The supply chain is an integrated system that must operate from end to end in a reliable, consistent fashion. If the people tasked with operating the supply chain are missing any of the key inputs, the entire supply chain system becomes unreliable or ad hoc, resulting in stockouts, increased supply related costs, and decreased coverage rates. A critical input into the supply chain is financing. Appropriate financial mechanisms need to be in place to keep vaccines and associated supplies moving through the chain. In decentralized systems, where different actors are responsible for the storage and distribution of vaccines at different stages of the supply chain, this financing can become complicated to quantify, manage, and distribute. Many low- and middle-income countries (LMICs) do not have adequate systems for tracking how the vaccination resource allocations flow through the system down to the point of delivery. Further, there is little documented insight into the financial bottlenecks or accounting methods to track actual compared to planned expenditures along sub- national levels.1 The result is that persistent weaknesses have been noted in securing funds at the lower levels of the chain to deliver vaccines to the child that needs it. 2 1 Kabaniha G, Zikusooka CM, Guthrie T. Financing for immunization at sub-national levels: a systematic literature review. UNICEF. May 2014. 2 Guthrie T, Zikusooka CM, O’Connell T, Kwesiga B, Abewe C, Lagony S, Kanoowe S, Mayanja R. Assessing sub-national bottlenecks for immunization services: piloting a rapid assessment approach. UNICEF. 2014. Page 4 Each country has its own unique challenges facing the immunization supply chain and financial flow, and which need to be evaluated individually in order to determine what is working and what needs improvement or re-evaluation. In Mozambique, the EPI program experiences frequent delays in funding which leads to gaps in on-time deliveries; however, it is not clear why these delays happen or how they can be prevented in the future. Without clarity about where and why the problems occur, appropriate improvements cannot be made. This study aims to identify financial flow bottlenecks in the country’s EPI program, and identify strategies to improve the financial flow to result in more efficient financial management and improved supply chain functioning for routine immunization. Importantly, this is not an academic exercise or extensive diagnostic that will capture all aspects of the financial flows for integrated health interventions. Instead the findings of this financial flow study have the potential to increase clarity regarding the immunization financial flow. Methods This study used the rapid assessment tool that was developed and first piloted by UNICEF in Uganda. The purpose of this tool is to assess areas of financial flow at each administrative level of the government and seeks potential solutions to financial flow issues.3,4 VillageReach and UNICEF Mozambique adapted the tool to the Mozambique context. The tool was designed to capture information about funding levels and budget requests, funding delays related to requisition and reporting requirements, and funding predictability based on staff’s opinions and perceptions. The VillageReach portion of this study targeted the heath sector and collected qualitative data through key informant interviews at national level, provincial (Gaza and Cabo Delgado), district (Meudumbe and Meluco 3 UNICEF. Addressing sub-national financial bottlenecks for immunization services: Piloting a rapid assessment approach. September 2014. 4 UNICEF. Financing for immunization at sub-national levels: A systematic literature review. May 2014. Page 5 in Cabo Delgado, and Manjacaze and Chibuto in Gaza), and health facility level (Chaimite in Chibuto district, Gaza, and Muaguide in Meluco district, Cabo Delgado). The following people were interviewed: National Director of Public Health, within the National Directorate of Public Health National head of EPI, within the National Directorate of Public Health, Ministry of Health National level Head of Administration and Finance Provincial heads of Administration and Finance District heads of Administration and Finance Directors, Provincial Directorate of Health (DPS) EPI Managers, DPS EPI Managers, SDSMAS Directors, District Directorate of Health (SDSMAS) Heads of health facilities EPI representatives at health facilities UNICEF conducted the same study in two districts in Zambezia where the Reaching Every Community (REC) project is being implemented. The two organizations collaborated with finalizing the survey tool and interviews at the national level MoH, as well as with the MoH partner Deloitte that provides technical assistance to the MoH in terms of financial systems and monitoring. Quantitative data from provincial and district level was also requested (see Annex 2) to track budget amount requested, received, and the duration of the process, using financial documents from 2014 as a benchmark. Results This study identified the financial process, from the planning stages to the dispersal of funds, in two provinces in Mozambique. In identifying the steps in the financial flow, several bottlenecks were found to impede the intended financial process. The following section will discuss how activities and budgets are planned and how those finances are intended to flow. Shortcomings and sources of delays will be identified and discussed. Non-governmental financial flows are also discussed, both in terms of their intended flow and how the processes are actually implemented. 3.1 Planning process The financing of Mozambique’s health sector is closely linked to the overall health sector
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