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Slide 1 - Zone Cours - HEC Montréal


									Service Delivery in Education and
         Health in Africa

            Bernard Gauthier
             HEC Montréal
1.       Introduction
2.       Public Service Provision Framework
3.       Origin and Motivations
4.       Main Findings
          Leakage
          Absenteeism
          Ghost workers
          Delays
          User fees
          Equity

5.       Illustration 1: Chad Health Sector
6.       Illustration 2: South Africa ECD programs
1. Introduction
 Access to quality services - in particular in health,
  education, water and sanitation - has been recognized
  as fundamental for wellbeing and economic
 However, in many African countries, access to quality
  services - in particular in health, education, water and
  sanitation, is often poor or non existents
       Service quality is low, basic materials, equipment, and staff are
        often lacking; access is difficult, costs are prohibitive for the poor,
        absenteeism, corruption, etc.

1. Introduction

   Inadequate service delivery is reflected in the poor
    results in terms of health and education outcomes.
       Current trends will not allow most countries to meet
          For instance, only 3 out of 46 countries in SSA is on track to
           meet target of reducing child mortality by 2/3 between
          Also, about 35 million children in SSA are not enrolled in
           primary school in 2006 (1/3 of the primary school age
           population) (UNESCO, 2008)
          Among adults, close to 40% of the estimated 161 million
           people in SSA remains illiterate, of which 62% are women.
          About 44% of population does not have access to safe
           drinking water,
          About 37% have no access to sanitation facility.              4
Source: World Development Report 2004, p. 134
Source: World Health Report 2003, p.8   6
1. Introduction

   To accelerate progress, donors, developing country
    governments and NGOs have committed increasing
    resources to improve service delivery in social sectors
       Low-income countries saw funding from external sources rise
        on average from 16.5% of their total health expenditures in
        2000 to 24.8% in 2007.
       Government commitments for health reported by bilateral
        donors jumped from about US$ 4 billion in 1995 to US$ 17
        billion in 2007 and US$ 20 billion in 2008. (WHR 2011, p.31)

1. Introduction

   However, increase expenditure is not sufficient to
    ensure improvements in service delivery performance
    and in population outcomes.
       Public service provision could be affected by institutional
        inefficiencies such as leakage of public resources,
        corruption, weak institutional capacity and inadequate
       Indeed, a growing body of research demonstrates a weak
        relationship between public expenditure and population
        outcomes (Filmer and Pritchett, 1999; World Bank, 2003)

1. Introduction


                  Source: World Bank (2003) World Development Report 2004, p. 11
1. Introduction
   Tel qu’observé par Filmer et Pritchett (1999), les résultats dans
    le domaine de la santé sont principalement fonction de 6
    variables principales :
   Ils estiment une fonction de production de la santé pour 100
    pays dans les années 1990 à l’aide de l’équation suivante :

   Où M est le résultat (mortalité infantile et juvénile), les variables
    exogènes sont le log du revenu par habitant, le log des dépenses de
    santé en proportion du PIB, H est le niveau d’éducation des femmes et
    X est un vecteurs d’autres variables socio-économiques (religion,
    groupes ethniques, localisation, etc.).
     ** Filmer, D. and L. Pritchett (1999) “The impact of Public Spending on Health: Does Money
        Matter?” Social Science and Medicine
1. Introduction

   Ils estiment par MCO et ensuite par moindres carrés en 2 étapes
    (2SLS) afin de tenir compte de l’endogénéité de certaines
    variables: :
       i.e. causalité qui va aussi dans l’autre sens): gouvernements
        des pays qui ont des niveaux de mortalité élevés peuvent
        dépenser plus en soins de santé afin de réduire ce problème
   Résultats indiquent que les dépenses officielles de santé n’ont pas
    d’effet significatifs sur la mortalité des enfants
   le revenu par habitant et l’éducation des mères réduit
    significativement la mortalité des enfants.
   Également, 1% de plus d’inégalité accroît la mortalité de 1%.
   La diversité ethnique accroît aussi la mortalité, de même que
    l’appartenance religieuse

Source: Filmer and Pritchett (1999)
1. Introduction

Also in education, while showing the highest spending per student as a
% of GDP per capita, Mali, Burkina Faso and Niger also present the
lowest primary enrollment rate and the lowest completion rates.     13
1. Introduction

     1. Introduction

At least 3 factors could explain this weak relationship:
1.   In several countries, social sectors expenditures are not
     mainly targeted toward the poor.
       •      Benefits incidence studies indicate that benefits accrue in a
              large proportion to rich and middle class groups. Ex: In
              Guinea, 48% of spending benefits the richest quintile.
2.         Even for public expenditures that target poor households,
           there could be significant differences between official
           spending in sector and actual spending at the provider level
       •      Corruption, rent capture and leakage of funds by the various
              layers of the political and administrative apparatus.
3.         Even if public resources reach frontline providers, the
           incentives for providers to produce quality services could
           be weak.
       •      Service providers in the public sector may be poorly
              remunerated, rarely monitored and incentives provided by
              the central bureaucracy may be lacking.
2. Public Service Provision Framework
   The quality of government provided services is function of a
    complex network of principal-agent relations:
       Characterized by delegation of responsibilities among
        clients/citizens, government and service providers.
   Citizens finance and delegate to government responsibility to
    provide services.
   The role of intermediary agent played by the government in
    the principal-agent relationship creates a situation where it is
    difficult for the principal (citizens) to evaluate and control the
    actions of the decentralized agent (service provider).
   Information about providers’ activities flows through
    hierarchical administrative structures (see Figure 1).
Public Service Provision Framework
 In an ideal world, with perfect information, citizens
  would be able to evaluate actions taken on their behalf by
  governments and service providers, and to exercise
  control over agents’ behavior.
 In practice, citizens have weak capacity to exercise
  control as:
        information is imperfect and asymmetric,
       agents’ objectives do not coincide with those of the principal
        (citizens), and enforcement is inadequate.
   The 2004 World Development Report has identified 2
    mechanisms by which citizens could exercise control in
    this context: The “long route” of accountability and the
    “short route” of accountability (see previous figure).
Public Service Provision Framework

    The “Long Route” of Accountability is the relationship
    between citizens and policymakers -- in which citizens have
    to hold politicians (policymakers) accountable for allocating
    resources for service delivery and for providing appropriate
    incentives for performance.
   However, it could be broken for several reasons.
   There could be non democratic electoral system, or important
    information asymmetries or social polarization, the outcome may
    still be biased against certain groups, especially the poor.
   Also, politicians in turn may not be able to hold the providers
    accountable for bad performance. Indeed, in many poor
    countries the institutions assigned to monitor providers are weak
    and malfunctioning
Public Service Provision Framework

  The “short route” of accountability between citizens and
   providers enables clients to monitor and directly discipline
   service providers.
  One way citizens can exert leverage directly on service
   providers are through various feedback mechanisms,
   which depend on systems assessing and reporting what
   clients think of service quality.
        For instance, public service’s users could be surveyed to gauge
         their satisfaction.
        They can also participate in providers’ management committees
         or oversight agencies or simply lobby, individually or through
         civil society organizations, for improved public services from
         various agencies.
Public Service Provision Framework

 Solutions to improve performance have focused on
  reducing information asymmetry and strengthening the
  accountability relationships, which are at the root of
  institutional deficiencies within service delivery systems.
 In addition, there is growing evidence that citizen
  participation in service delivery and better information
  can help improve outcomes, especially using
  mechanisms that enable clients to monitor and directly
  discipline service providers (World Bank, 2003;
  Banerjee et al., 2006).
Public Service Provision Framework

    Indeed, new approaches and tools are being developed
     to improve health and education for the poor—which,
     in turn, would boost economic and social development
1.    Self interest/diverging objectives
      Modify the incentives and interest of agent by moving
      them closer to those of the principal.
      Incentives/Contract: salary based on the performance
      of organization or department
2.    Asymmetry of information
      Create mechanisms of supervision and control. Collect
      information, indicators.
Public Service Provision Framework

   In the last decade, “new” survey tools have been developed to
    provide adequate information on decentralized levels and service
    providers, to evaluate the efficiency or equity of government
   Public Expenditure Tracking Survey : seek to track flows of
    funds and materials from the central government to basic service
    providers, via regional and local governments, to identify
    evidence of waste, inefficiencies and corruption.
     Verify if effective budget allocation at facility level corresponds to intended/official goals
•   Quantitative Service Delivery Survey: analyze the performance of
    service provision at facility level (to measure inputs, outputs and,
    for example, to analyze incentives)
Public Service Provision Framework

   Observational Study: Measure the quality of services, proxied for
    by the level of effort exerted or health vignettes (case studies that
    assess adherence to clinical protocols and diagnostics)

   Citizen Report Cards : Instrument to promote citizen awareness
    and participation. Used to collect information from users about
    experiences of service quality, disseminated back to
    citizens/users so have reliable information about how their
    community experiences quality and efficacy of service delivery.

   These instruments have proven to be powerful tools for
    identifying bottlenecks, inefficiencies and waste

3. Origin and Motivations of the First PETS and QSDS

   The first PETS was implemented in Uganda in the
    education and health sectors in 1996.
   The country was facing stagnant and even declining
    education and health outcomes despite important increases
    in expenditures in these sectors in the past decade.
       In education, despite the tripling of public expenditures,
        official primary school enrolment figures were stagnant.
   The central government had very little information about
    resource use and reasons for poor outcomes
       but it was suspected that local governments might be
        diverting resources for other purposes.
3. Origin and Motivations of the First PETS and QSDS

   The objective of the survey was to track expenditure flows
    in the hierarchical structure to identify factors explaining
    these poor results, and to measure potential leakages in
    school and health facility funding.
       Hypothesis for poor results was that public resources did not
        reach schools and health facilities (Ablo and Reinikka, 1998).
   Survey instruments were developed to compare official
    budget allocations with actual spending at various tiers of
    government, including primary schools and dispensaries.
   The survey consisted of three instruments.
       Data were collected at the central level, the district level (local
        government), and the public primary school and public health care
        facility level.                                                     26
3. Origin and Motivations of the First PETS and QSDS

   In the education sector, the tracking exercise focused
    especially on a specific fixed-rule program
       “capitation expenditures” to schools--which was officially
        based on enrolment figures at the school level.
   The tracking survey in education was able to identify
    various problems in the sector, in particular large-scale
    resources leakage.
       On average, only 13% of the annual capitation grant from the
        central government reached the schools in 1991–95.
       Most schools received no grants at all.
       87% was captured by local officials for purposes unrelated to
        education, yet there was no evidence of increased spending in
        other sectors (Jeppson, 2001).                               27

      Tableau 3: Dissipation des ressources non salariales dans le secteur de l’éducation
                    primaire en Ouganda, 1991-95 et 2001 (pourcentage)
                                        Moyenne                Médiane
     1991                               97                     100
     1992                               96                     100
     1993                               85                     100
     1994                               84                     100
     1995                               78                     100
     2001                               18                     18
     Source : Reinikka (2001) et Reinikka et Svensson (2004)
3. Origin and Motivations of the First PETS and QSDS

   Following the tracking survey findings, the government
    implemented policy reforms, including an information
       Published monthly intergovernmental transfers of capitation
        grants in the main newspapers and requiring primary schools
        to post information on inflows of funds.
   An evaluation of the information campaign—using impact
    evaluation PETS in 1999 and 2001—reveals great
       While schools on average are still not receiving the entire
        grant, capture has been reduced to 18% in 2001.
   This success drew considerable attention to the new survey
    tool (Reinikka and Svensson, QJE, 2004).                          29
3. Origin and Motivations of the First PETS and QSDS

   First QSDS also implemented in Uganda in health sector (2000)
      Despite an increasing health budget, health services were
       perceived as not meeting the needs of the population as health
       indicators (in particular immunization rates) were declining
   Survey collected quantitative and expenditure data at facility
       Information was collected from the head nurse or head doctor on
        infrastructure, inputs, output, financing, staffing and incentives (e.g.
        remuneration, institutional support, supervision).
   Also collected information at the district health administration
    level on various elements
       e.g. inputs, staffing, drugs, vaccines supplies and supervision
   An exit poll of patients was also conducted to gather information
    on the demand side,
       e.g. individuals’ characteristics, behavior and perceived quality of services.
3. Origin and Motivations of the First PETS and QSDS

   Since then, more than four dozen PETS and QSDS,
    (as well as combined PETS-QSDS), were launched in
    low income countries, the majority in Africa.

   Most of these surveys were conducted in the health
    and education sectors

   A few also comprised works in other sectors, such as
    water supply, agriculture, rural roads, ECD...

4. PETS/QSDS Main Findings
 Public resources leakage has been identified on a very
  large scale (Table 1).
 For instance:
      As mentioned, the initial Uganda PETS estimated that 87%
       of capitation (per-student) grants for did not reach its
      Tanzania and Ghana: leakage on non-wage education
       expenditures was 41% and 50% respectively
      Zambia: Important differences in efficiency/leakage between
       discretionary (76%) and rule-based funding (10%)
Main Findings

                     Table 1: Leakage levels (%)
 Country                      Education            Health
 Chad, 2004                       -                 80
 Ghana, 1998                     49                 80
 Kenya, 2004                      -                 38
 Tanzania, 1998                  57                 41
 Uganda, 1991-95                 87                  -
 Zambia , 2001             10 (rule-based)           -
                          76 (discretionary)
  -- Not available
Main Findings

Definitions of leakage:
 The “strict” definition of leakage introduced by Ablo and
  Reinikka (1998) for rule-based expenditures (hard allocation
  rule) is the share not received with respect to the expected
  (fixed-rule) entitlement:

   For non-fixed (soft) allocation rule flows (discretionary):
    “broad” definition: share of resources sent at a certain level
    and not received at the other, in particular the facility level:

Main Findings

   PETS/QSDS have also allowed to measure provider
   Results show absenteeism rates of between 27 and 40
    percent for health care providers and between 11 and 27
    percent for teachers.
       Absenteeism rates were associated with poverty and community
        characteristics related to effectiveness in monitoring.
   Because of poor accountability relationships and weak
    incentives, service provider absenteeism is prevalent in
    developing countries, which translates into low quality of
    services.                                                          35
Main Findings

Main Findings

Ghost Workers
 In a few countries, tracking surveys allowed to measure
  “ghost workers”
       Proportion of teachers or health workers who continue to
        receive a salary but who no longer are in the government
        service, or who have been included in the payroll without
        ever being in the service
   In Papua New Guinea, a 2003 PETS for ex. showed that
    15% of teachers on the payroll were ghosts.
   In Africa, the comparable figures are even higher: 20% in
    Uganda in 1993

Main Findings

                        Table 2. Ghost workers on payroll (%)
   Country                                      Ghosts workers
                                        Education                        Health
   Honduras, 2000                            5                             8.3

   Papua New Guinea, 2002                    15                             _

   Uganda, 1993                              20                             _
         Source: World Bank (2001) for Honduras; World Bank (2004) for Papua New Guinea;
         and Reinikka (2001) for Uganda.-- Not available.
Main Findings

 Delays and bottlenecks in the allocation of resources
  have also been measured
       Salaries, allowances, financing, material, equipment, drugs and
   These issues could have important effects on the
    quality of services, staff morale and the capacity of
    providers to deliver services.
       In some countries, such as Nigeria, in one state, 42% of the
        health staff respondents reported not receiving salaries for
        the 6 months or more.
Main Findings

User fees
   Tracking surveys have produced findings on the importance
    and impact of user fees.
       In several countries (e.g. Chad, Mozambique), user fees are
        sometimes the only source of revenues for service providers.
   On the demand side, however, they often constitute a very
    important part of service costs for users and could have
    considerable negative effects on accessibility.
       For instance in Uganda, although the government was trying to
        re-establish free education, the survey found that private
        contributions represented more than 60% of education costs at
        the school level.
       In Chad, for the poorest quintile, the average out-of-pocket
        medical expenses accounted for 21% of their monthly incomes. 40
Main Findings

 In several countries, large variability of health and
  school spending across regions and districts, as well as
  within districts, was observed
       For instance: Mozambique, nine-fold variation of per capita
        health spending at the district level
       Chad: non-wage per capita public health spending showed
        important variations across districts (in a 16 to 1 ratio)
       Zambia: the most funded school district received 8 times
        more average per-student public resources than the least
        funded district.

5. Illustration: Chad Health Sector
   A combined PETS-QSDS was organized in the Chadian health
    sector by the World Bank in 2004.
       See : Gauthier and Wane (2009) “Leakage of Health Resources in Chad”,
        Journal of African Economies
   In a context of increasing oil revenues and public expenditures in
    social programs, government of Chad and international donors
    wanted to ensure that funding contribute to poverty reduction
    objectives by reaching its destination and benefiting the population.
       Chad: pop 10.5 million, one of poorest countries US$450 per capita,
        ranks 170 out of 177 countries in Human Development Index (2008)
       Adult illiteracy rate is 74.5%. Only 34% of the population has access
        to improved water and 8% to sanitary facilities.
       Life expectancy at birth is 43.6 years and the child mortality rate
        (under 5 years) is 200 per 1,000 live births. Mother mortality is among
        the highest in Africa, close to 1100 for 100,000 live births.        42
Chad Health Sector

   The health system in Chad is composed of a mixture of
    public, private for-profit and non-profit service providers.
   The public health system is structured around four levels of
    responsibility (Figure 4).
   Public health care providers (except some hospitals) do not
    receive any financial resources from the public administrative
    system, only in-kind resources.
       User fees are the only source of financial resources at the local
        provider level.
   Public resources arriving at decentralized levels from the
    Ministry of Health (MOH) are the sum of four components,
    namely (1) centralized credits, (2) decentralized credits, (3) ad
    hoc requests, and (4) medication and vaccine delivery.
Chad Health Sector

Chad Health Sector

   Centralized credits are resources purchased by the MOH
    (essentially materials and medications), intended for regional
    and district administrations and health centers
   Delegated credits are budgetary resources given to regional or
    district administrations.
   Resources are also transferred through ad hoc requests
       These materials are directly requested from the MOH and collected
        by regional health delegates and district heads in the capital.
   There is a budget for medications and vaccines destined for
    health centers and hospitals administered by the Central
    Pharmaceutical Procurement Agency (CPPA),
       Has a monopoly over drugs and medical products sold to the 14
        Prefectoral Purchasing Pharmacies (PPP), as well as to the public
        and non-profit health facilities.                                   45
Chad Health Sector

   The survey focused on the health system as a whole (primary,
    secondary and tertiary health care providers).
   The objective was to compare resource access and level of
    services in health centers of all the country’s regional
       Specifically, the objectives were to analyze the impact of and
        bottlenecks and constraints in resource allocation and their
        impact on efficiency and performance of health care facilities;
   In addition to facility level data, information was collected at
    all levels of the public administration (MOF, MOH, regional
    delegates, district head doctors and regional pharmacy
   A staff questionnaire and a patient exit poll were also
Chad Health Sector

Tracking Strategy
 Survey focus on all recurrent expenditures and tracked
  all financial resources from MoH to Health centers +
 Traced 8 medical materials received by health centers
       Mattresses, beds, sheets, blankets, blouses for nurses and
        midwives, soap and detergent.
   The choice of materials was based on their frequency in
       The risk of choosing a rare but high-value material would
        have been not finding that material in the visited health
        centers simply because not all of them were able to receive it.
Chad Health Sector

       On the contrary, by choosing frequently-shipped materials of
        small value, it is likely that a maximum number of health
        centers will report receiving them.
       This gives us an upwardly biased percentage of health centers
        receiving materials from the authorities.
 Traced also 11 drugs and medical consumables received
  by HC
 Also based on frequency of shipping
 Total value of resources reaching the health centers is
  the sum of the financial resources, medical materials,
  drugs and salaries received by health centers from the
  health administration.
5.1 Data
   Questionnaires administered to regional delegates, district head
    doctors and health center heads in all the regions of the country,
    in half of the districts and about half of the health centers.
   281 health centers and 35 hospitals surveyed
   1/3 of capital’s health centers are private vs 1/4 in other urban
    areas and 6% in rural areas.

5.2 The Extent of Leakage in the Health sector
     Health budget in 2003 represented 8.4% of the total
     government budget (an increase of 24% over 2002)
        Support from foreign donors : 48% of health budget.

    The analysis focuses on MoH recurrent expenditures (which
     represented 48% of the total budget) because of the absence
     of information concerning investments.

A.   Public Resources Reaching the Regional Level

    About 60% of the MoH recurrent budget (2/3 of the MoH
     non-wage recurrent budget) is devoted to the14 regional health
     delegations (RHD)
- 86% of the regional budget is controlled by MoH through centralized credits.
- Remaining 14% of the regional health budget is managed at the regional level
through decentralized credits                                                  51
                                              Figure 1: Official vs. Effective Expenditures
                                                    by Regional Health Delegations
                          1000                                                                45

                          900                                                                 40

 Millions of CFA Francs


                                                                                                   Percentage Received
                          600                                                                                            Initial Allocation
                                                                                                                         Resources Received
                          400                                                                                            Average



                          100                                                                 5

                            0                                                                 0








                                                  ne nta









                                                          r ie
















• On average, RHDs received only 26,7% of their official non-wage budgetary
                                                      expenditures from the MoH                                                     52
The Extent of Leakage in the Health sector

B. Public Resources Reaching Health Centers
   Health center administrators report receiving about 50
    million CFAF of medical materials accounting for 17.8% of
    materials received by all RHDs

   Only 4 centers (2%) report receiving financial resources
    from the health administration in 2003.

   Total value of medication received by HC is estimated at
    3% of the MOH official medication budget.

     See Document: Medication leakage in Chad                 53
•Leakage is also pronounced at the regional level, since the health centers
      ultimately receive about 1% of MoH non-wage expenditures.
  •Given leakage, the main source of health center financing is user fees
  •Government transfers account for only 2% of health center revenues
(excluding salaries) and for one-quarter of their revenues including salaries.
5.3 Empirical Analysis
A. Impacts of Public Resources on Health
 Do public expenditures have an impact on output in
    the health sector, in terms of patients treated in health
       Several studies have questioned this relationship (e.g.Filmer
        et al, 2000).
   We compare the effects of official health
    expenditures and effective health expenditures in
    regional delegations and the number of patients
    visiting local health centers per 1,000 inhabitants in a
    region (Figure 3).                                             56
Impacts of Public Resources on Health Production

   We examine the relationship between official vs effective
    resources and health services:
                      Cl   l   2 l   l
   Where Cl is the number of patient consultations taking place
    annually in a region or a district l
   Yl is a vector of region or district characteristics, including:
        Official or effective health expenditures in the region or district,
        Number of health centers and districts,
        Population served,
        Total revenues of health centers
        Total salaries.
Impacts of Public Resources on Health Production

   Official health expenditures do not explain health output at
    the regional level (columns 1-3, table 9).
   Effective health expenditures are always positive and
    significant (columns 4-8)
   Real public expenditures have a positive impact on health
    output at the regional level.
       For a million CFAF (US$1720) of effective public expenditures
        received in a region, 693 more patients would receive medical
        consultations in primary health centers in the region (column 6).
       We can estimate that close to 3 million patients do not visit
        health centers because resources do not reach service providers.
       If all public resources had reached frontline providers, number
        of patients seeking primary health care would have doubled.
Empirical Analysis

B. Leakage of Resources and Mark-up
   One possible mechanism by which actual receipt of public
    resources would allow better access to health services is through
    the reduction of user fees in particular medication prices.
      In Chad, medication costs account for 75% of total medical
       costs for patients (85% in rural areas).

   Most HC have a pharmacy that sells drugs to patients.

   Survey collected information on 11 of the main drugs allocated by
    the MoH to intermediate levels and HC, as well as information on
    medication purchase prices at regional pharmacies and sale prices
    to patients.
Leakage of Resources and Mark-up

   Relationship between leakage of public expenditures and drug
    mark-ups using OLS with clusters by regions (Table 10, columns
    1 to 4).

   Econometric issue: Level of competition among HC is unlikely
    to be exogenous
       Certain types of health centers are more likely to be located in
        certain areas.
       In particular, private health centers are more likely to be located in
        urban areas and confessional centers in rural areas.

   In order to obtain unbiased estimates, we have estimated
    simultaneous equations of the determinants of mark-up and
    competition, using 3SLS method (columns 5-6).
Empirical Analysis

 Leakage has a negative and significant impact on the
  prices of medications sold by health centers.
      Health centers that do not receive public support tend to
       charge significantly higher mark-ups on medications

      Leakage of government resources thus appears to have a
       significant and negative effect on user fees and to
       constitute a barrier to health service access.

       Greater competition among HC tend to significantly
       reduce average mark-up on drugs and thus be favourable
       to users.
5.4 Conclusion
   Because of leakage, the official health budget bears no relation to
    the actual situation on the ground.
       Despite that 60% of MoH recurrent budget is officially allocated to
        regions, HC receive only about 1% of non-wage resources
        Although the government officially allocates 680 CFAF (US$1.17) in
        health expenditures for the average Chadian, that person actually
        receives less than 10 CFAF (US$0.02).
   Contrary to pessimistic views, health expenditures do in fact have
    a positive impact on health services.
       Expenditures reaching health centers have a positive and significant
        impact on number of patients treated.
       If all expenditures officially targeted to regions had actually reached
        HC, the number of patients treated would have doubled.

    Leakage has a negative and significant impact on the prices of
     medications sold by health centers.
         Health centers that do not receive public support tend to charge
          significantly higher mark-ups on medications
    Since the beginning of the “New initiative in the context of
     petroleum production” in Chad, expenditures in health and other
     social sectors have increased but without noticeable impacts on
     social indicators.
         The low percentage of public resources actually received at the
          operational level could certainly explain a large part of this
    A major reform of the public management and public expenditure
     system is required in order for service facilities and the population in
     general to benefit from public resources

   Because of leakage, the official health budget bears no
    relation to the actual situation on the ground.
       Despite that 60% of MoH recurrent budget is officially allocated
        to regions, HC receive only about 1% of non-wage resources
        Although the government officially allocates 680 CFAF
        (US$1.17) in health expenditures for the average Chadian, that
        person actually receives less than 10 CFAF (US$0.02).
   Contrary to pessimistic views, health expenditures do in fact
    have a positive impact on health services.
       Expenditures reaching health centers have a positive and
        significant impact on number of patients treated.
       If all expenditures officially targeted to regions had actually
        reached HC, the number of patients treated would have
        doubled.                                                          68
6. Illustration: South Africa Early
Childhood Development
   PETS/QSDS organized by UNICEF on ECD in SA: ongoing
   ECD presented as one of top 4 priorities of SA government
   Children covered in ECD programs are 0-4 years & 5-6 years
    (Grade R)
   Central government is responsible for setting policies,
    regulation and oversight, while 9 provincial governments are
    responsible for policy implementation.
   Two main departments involved in ECD services:
    Department of Social Development (DSD) and Education
       DSD has main responsibilities with respect to service provision
        while DOE mainly responsible for training of personnel and
        service quality.
South Africa Early Childhood Development

 While the central government has invested important
  resources for ECD in the last few years, difficult to
  determine if translate into actual spending at the
  provincial or facility level given central government’s
  views and budgetary expenditures are only indicative.
 Provinces are responsible for establishing their own
  allocation rules and for ensuring efficiency of spending
 At the central level, the DSD budget transfers to
  provinces are done through the “Children” budget line
  part of an “equitable share” formula.
 The National treasury or central ministries have no
  power to earmark ECD resources at provincial level.
South Africa Early Childhood Development

   Once transfers are made to the provincial treasury, they are
    allocated to provincial departments. At the provincial level,
    the budget allocated to the DSD includes amount for the
    department own administrative use and another for
    transfers toward facilities for service delivery.
       Ultimately, subsidy per child at facility level varies between 4.5R
        and 11R
   Facilities receive the subsidies
   Parents have little information on subsidies (not made
    public) Provincial DSD have weak enforcement capacity.
       There is no roster of students who qualify for subsidies or
        verifications of these lists
   This means that possibility of leakage will occur                     71
South Africa Early Childhood Development

   Ultimately, current coverage of ECD programs is low.
    Currently, only about 20% of children of 0-5 years
    attend ECD programs, mostly 4-5 year age group.
       Various factors could explain low attendance including high
        user fees discouraging usage, geographical access,

   Combined PETS/QSDS focuses on establishing
    baseline data on the efficiency and quality of ECD

   3 provinces covered: Western Cape, North West and

   Sample: About 600 facilities (200 by province)                    72
South Africa Early Childhood Development

      PETS/QSDS of ECD: main topics
      Equity and efficiency challenges (across and within
      Resource availability and use, unit costs, users’ fees, etc.
      Human resources at sites, characteristics, incentives, etc.
      Standard and norms in service provision
      Financial and administrative capacity of management

South Africa Early Childhood Development

   Tracking expenditures through government system toward
    service delivery facilities and measuring the level of services.
   Baseline data collection includes information on: i) Process
    (i.e. inputs); ii) Intermediate outputs (e.g. enrolment levels,
    dropout rates)
   Some preliminary results:
       Huge differences of services access and quality across and within
        provinces (rural vs urban, poor vs rich communities)
       Within facilities: subsidized and non subsidized users pay same
       Poorest communities and households not subsidized : i.e. don’t
        meet minimum requirements (e.g. infrastructure) : middle-class
        receive transfers
   Draft instruments and other material available
South Africa Early Childhood Development


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