BELOW THE GLASS FLOOR Analytical Review of Expenditure by Provincial Administrations on Rural Health from Health Function Grants & Provincial Internal Revenue JULY 2013 Below the Glass Floor: An Analytical Review of Provincial Administrations’ Rural Health Expenditure Rights and Permissions The material in this publication is copyrighted. Copying and/or transmitting portions or all of this work without permission may be a violation of applicable law. The International Bank for Reconstruction and Development/ The World Bank encourages dissemination of its work and will normally grant permission to reproduce portions of the work promptly. For permission to photocopy or reprint any part of this work, please send a request with complete information to the Copyright Clearance Center Inc., 222 Rosewood Drive, Danvers, MA 01923, USA; telephone: 978-750- 8400; fax: 978-750-4470; Internet: www.copyright.com. All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street, NW, Washington, DC 20433, USA; fax 202-522-2422; email: [email protected]. - i - Below the Glass Floor: An Analytical Review of Provincial Administrations’ Rural Health Expenditure Table of Contents Acknowledgment ......................................................................................................................... 5 Abbreviations .............................................................................................................................. 6 Executive Summary ...................................................................................................................... 7 Background ............................................................................................................................... 13 Chapter 1: Introduction .............................................................................................................. 14 Chapter 2: Spending on Frontline Service Delivery Activities in Rural Health ................................ 17 The Importance of Timely Funding from Waigani ................................................................... 17 The Overall Picture of Provincial Spending on Health ............................................................. 20 Chapter 3: Spending on the Operation of Rural Health Facilities (MPA 1) ..................................... 23 Chapter 4: Spending on Integrated Rural Health Outreach Patrols (MPA 2) ................................... 28 Chapter 5: Spending on the Distribution of Drugs and Medical Supplies (MPA 3) .......................... 31 Chapter 6: Other Spending Priorities ........................................................................................... 34 Spending on Patient Transfers from Rural Facilities ................................................................. 34 Spending on the Provision of Clean Water Supply ................................................................... 36 Spending on Supervision Activities .......................................................................................... 39 Chapter 7: Summary and Next Steps ........................................................................................... 40 Key Findings ............................................................................................................................. 40 Proposed Fieldwork ................................................................................................................. 43 Appendix 1: Country Summary – Papua New Guinea (and Comparators) ..................................... 44 Appendix 2: The Rural Health Context ........................................................................................ 45 Appendix 3: Funding Streams for Rural Health ............................................................................ 49 Appendix 4: Activity Spending versus Cost Estimate .................................................................... 59 Appendix 5: Analytical Methodology .......................................................................................... 60 Appendix 6: An Explanation of the NEFC Analytical Methodology for the Provincial Expenditure Review (PER) .................................................................................................................. 61 Appendix 7: Proposed Fieldwork Questions ................................................................................ 63 Glossary..................................................................................................................................... 66 References ................................................................................................................................. 67 - 2 - Below the Glass Floor: An Analytical Review of Provincial Administrations’ Rural Health Expenditure Boxes Box 3.A.1: Indonesian Case Study ......................................................................................................... 57 Figures Figure 1: Spending on Frontline Services (2006-10) ............................................................................... 8 Figure 2.1: Cash Release by February in 2008-10 (by Region) .............................................................. 18 Figure 2.2: Warrant/Cash Released via Health Function Grant by July (2010) ..................................... 19 Figure 2.3: All Provincial Spending on Health (2006-10) ...................................................................... 20 Figure 2.4: Recurrent-only Provincial Spending on Health (2006-10) (by Source) ............................... 21 Figure 2.5: Provincial Health Spending From Own-source Revenue (2006-10) .................................... 21 Figure 2.6: Morobe’s Reduced Spending From Own-source Revenue (2006-10) ................................. 22 Figure 3.1: Provincial Spending on the Operation of Rural Health Facilities (by Region) ..................... 25 Figure 3.2: Provincial Spending on the Operation of Rural Health Facilities (by Fiscal Capacity) ............................................................................................................................................... 26 Figure 4.1: Provincial Spending on Integrated Rural Health Outreach Patrols (by Region) .................................................................................................................................................. 29 Figure 5.1: Provincial Spending on the Distribution of Drugs and Medical Supplies (by Region) .................................................................................................................................................. 33 Figure 6.1: Provincial Spending on Patient Transfer (by Region) .......................................................... 35 Figure 6.2: Provincial Spending on the Provision of Clean Water Supply (by Region) .......................... 38 Figure 6.3: Provincial Spending on Supervision Activities (2010) ......................................................... 39 Figure 2.A.1: The Sub-national Service Delivery Supply Chain ............................................................. 46 Figure 3.A.1: Health Fund Flows ........................................................................................................... 53 Figure 3.A.2: Estimated Provincial Fiscal Capacity (2012) .................................................................... 55 Figure 3.A.3: A Funding-of-Activities Approach in Rural Health ........................................................... 57 Tables Table 1: Activity Spending versus Cost Estimate (2010) ........................................................................ 10 Table 2: Rural Health Provincial Profiles................................................................................................ 11 Table 3: A Proposed Warrant Release Schedule .................................................................................... 20 Table 7.1: Summary of Activity Spending versus Cost Estimate (2010) ................................................ 41 Table 2.A.1: Standard Set of Provincial Health Activities and Cost Centers .......................................... 47 Table 3.A.1: Funding to Rural Health for Recurrent Operations (millions of Kina) ............................... 50 Table 3.A.2: The Nature of the Funding Sources for Rural Health’s Recurrent Operations ............................................................................................................................................. 52 - 3 - Below the Glass Floor: An Analytical Review of Provincial Administrations’ Rural Health Expenditure Table 3.A.3: Actual Fiscal Capacity to Fulfill Estimated Cost of Services (2010) ................................... 54 Table 3.A.4: Estimated Fiscal Capacity (2012) ....................................................................................... 55 - 4 - Below the Glass Floor: An Analytical Review of Provincial Administrations’ Rural Health Expenditure Acknowledgment This study was undertaken jointly by the World Bank (WB), the Australian Agency for International Development (AusAID), and the National Economic and Fiscal Commission (NEFC). The World Bank coordinated and led the review under the Program of Analytical and Advisory Activities in the health sector in PNG. Alan Cairns led the design of the conceptual framework, undertook the analytics and wrote the report under the task leadership of Aparnaa Somanathan (World Bank). The