Corruption in the health sector

Budget transparency

Transparency:   standards and promotion

CONTENT ON THIS PAGE:

•  Transparency standards
•  Measures to promote budget transparency
•  National health accounts and the budget process
•  Public participation in the budget process

Transparency Standards

Regulation for budget transparency exists on national and international levels, and applies to all sectors of the public services. Many developing and transitional countries have legislated, and, to a lesser degree, provided greater availability of budget information in recent years.

The International Monetary Fund's (IMF) Code of Good Practices on Fiscal Transparency developed in the context of the collapse of the Asian financial system and adopted in 1998, provides a coherent framework to assess the transparency of public finances, to identify priorities for reform, and to monitor progress. The Code defines (i) clarity of roles and responsibilities in public finance, (ii) public availability of information, (iii) open budget preparation, execution and reporting, and (iv) independent assurances of integrity (external audit). The IMF also issues country reports on fiscal transparency that measure country performance against the Code. The OECD has developed Best Practice on Budget Transparency (2001) that also provides a benchmark for government performance. On the national level, some countries have enacted specific regulations for fiscal transparency. Budget transparency is defined as "full disclosure of all relevant fiscal information in a timely and systematic manner" in the OECD Best Practices for Budget Transparency.

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Measures to Promote Budget Transparency

If the budget were open to public and effective legislative scrutiny, there would be less scope for deviation from policy decisions and reversal of budget allocations. There would probably be fewer distortions between the sub-sectors, and the ruling elite would be less likely to manipulate the budget. Budget transparency, while not a goal in itself, is a prerequisite for public participation and accountability: A budget that is not transparent, accessible and accurate cannot be properly analysed. Its implementation can also not be thoroughly monitored, and its outcomes can not be evaluated. There are a variety of measures and tools that enhance budget transparency.

• Avoiding off-budget activities
  In the budget presentation, the full picture of the governments' financial status must be given. Many developing countries have lost control over their financial affairs due to the segregation of budgetary execution data, and/or ad hoc budgetary execution records. Donors should be particularly aware that off-budget programmes should be avoided or, if deemed necessary, be fully transparent: Aid practices can otherwise distort the budgetary process and undermine government accountability.
  
  
• Sound budget and expenditure management systems
  Ideally the budget system should be built in such a way that it is transparent and open to public scrutiny. Improved public expenditure management systems are currently put in place in many developing countries in the context of the Poverty Reduction Strategies (PRS). They are part of an overall "reform package" consisting of macro-economic and budget reform, civil service reform, and changes in the legal and regulatory structures, and often appear as conditions attached to International Monetary Fund (IMF) and World Bank lending and debt relief. Many recipients budgetary systems have much better data on the input mix for domestically financed expenditures than they do on donor projects, which are sometimes treated as single lines in the budget.
  
  
• Making information available
  The budget system should be designed in such a way that it "produces" comprehensive, timely information. Communication technology can play a crucial role in this. Electronic records of all transactions can contribute to avoiding expenditures without previous authorisation and proper justification. For example, in Peru, an Internet Portal of Fiscal Transparency has been providing free access to detailed budget information since 1999. Pro-active government or NGO information campaigns can generate public interest in monitoring spending and thus prevent leakage of funds.
  
  
• Build budget literacy
  Understanding and analysing budgets is not an easy task. However, if citizens are to hold their leaders to account, they have to be able to understand the budget. The legislature is more likely to effectively monitor the budget process if there is widespread public interest in budget issues. The media and NGOs play a particularly important role in regard to generating interest and sparking public debates about the budget. In recent years, many NGOs have specialised in budget analysis and offer training for other civil society organisations.
  
  
• Develop capacity of parliamentarians
  Budget literacy is particularly important for Members of Parliament (MPs) who should be able to analyse and comment on the budget proposal, and to monitor expenditures and evaluate the budget outcomes at the end of the fiscal year. MPs have an important role to play: They can initiate public hearings and debates, establish special committees and request further information from the executive. Aid agencies seldom hold a dialogue with parliamentarians, who sometimes view the donor emphasis on civil society as undermining the legitimacy of elected representatives.
  
  
• Public Expenditure Tracking
  In the budget execution phase, transparency can be enhanced through expenditure tracking, a method of finding out how expenditure is being made, and how and at which level of the system the money is disappearing. It examines the flow of public funds and the extent to which resources actually reach the target group. Public Expenditure Tracking Surveys (PETS) measure the transformation of public expenditure into public goods and service delivery. The World Bank website on PETS provides links to several papers that describe this methodology, as well as results from some countries. Other resources include a publication by Ritva Reinikka and Nathanael Smith, Public Expenditure Tracking Surveys in Education, produced by the United Nations Education, Scientific, and Cultural Organization (UNESCO) International Institute of Education Planning (IIEP) in 2004; and the web site of Oxford Policy Management where consulting teams have participated in PETS studies in several countries, including Mozambique and Bangladesh. Reports and lessons learned are posted on the OPM web site, including Lessons from Bangladesh and the Mozambique summary. The full Mozambique expenditure tracking and service delivery survey in combination with quantitative service delivery surveys of specific facilities can yield useful information on the contours of corruption and identify entry points for reform. The World Bank and the IIEP offer training courses on the PETS methodology.
  
  
• Strong and independent audit institutions
  It is unfortunately not always the case that professional bodies that review and evaluate fiscal activities, such as audit institutions, are able to do their job. Means to enhance budget transparency should therefore also aim to strengthen the effectiveness of audit institutions. To effectively monitor and assess public spending, they need political independence as well as adequate financial and human resources that allow them to produce accurate reports in a timely manner.
  Another prerequisite for effective audit institutions is a strong legal framework that is able to enforce regulations for spending as well as the fiscal relations between central and local government.

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National Health Accounts and the Budget process

National Health Accounts (NHA) is an internationally recognised framework that measures and tracks the use of total health care expenditures in a country. NHA tracks the flow of funds from one health care dimension to another, such as from the Ministry of Health to each health provider and health service program. Expenditure data is presented in a standard set of tables intended for use by country policymakers and other stakeholders, including donor representatives. Thus, NHA allows for greater fiscal transparency of country health systems and fosters an anti-corruption approach NHA requires health care spending information from all health sector stakeholders. This need for transparency allows NHA to serve as an anti-corruption tool, especially when implemented on a regular basis; governments, insurance companies, and other stakeholders remain more vigilant about distribution of their health funds in anticipation of sharing such information each year.

Donors play a critical role in initiating government interest in and commitment to NHA. One source of information about donor NHA activities in Africa is the WHO/AFRO, the elected co-ordinating body of African NHA regional network. In addition, the USAID-funded Partners for Health Reform plus Project has a special section on NHA analysis, links to regional networks, and reports from many countries.

The Commonwealth Regional Health Community Secretariat is an additional source of information on Anglophone countries, see Brief for Donors: National Health Accounts: Supporting NHA in Africa. See also NHA information on Latinamerica.

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Public Participation in the Budget Process

Public participation is one important component of a more accountable public sector. Corrupt use of resources cannot be prevented through regulation, good management and transparency alone. The public needs to actively use the budget information that is available to them. The information that is produced through budget transparency should be used for public debate and formulation of policy; otherwise budget transparency has no effect. Civil society and the media should engage in budget debates. Ultimately, it is the citizens who finance the budget and therefore they should be benefiting from public spending. The public can actively be included in all stages of the budget cycle.

• Participatory budgeting
  Participatory budgeting is an innovative financial practice that involves people in priority-setting and resource allocation. It has become increasingly popular in the context of decentralisation that creates opportunities for greater citizen and local legislative involvement. Participatory budgeting helps improve transparency in finance administration of local authorities; contributes to a more equitable distribution of resources and to eliminate "party politics" in local decision-making. It breaks with the tradition that the budget process should occur exclusively in the executive, with the input only of budget technicians and a few politicians. Participatory budgeting tools have been widely applied in Latin America and Europe.
  
  
• Budget monitoring by Non-Governmental Organisations (NGOs)
  An increasing number of NGOs carry out independent research and training with the aim of building public awareness on budget issues. NGOs are involved in budget analysis, providing comprehensive information to the public and to the media and often enabling them to comment on budget proposals and to monitor expenditures. NGOs also carry out surveys to compare budget transparency across countries, thus putting pressure on governments to improve budget systems.
  
  
• Public hearings and citizen score cards
  Two examples of tools that generate public awareness and citizen engagement in budget processes are public hearings and score cards for public services. Public budget hearings at local level raise citizens' awareness on goods and services that are supposedly delivered to them. Presenting expenditure records in easy language to the public and confronting local politicians with the discrepancy between policy statements and actual delivery can trigger civic action against corruption and contribute to accountability. Report cards for public services measure both quantitative and qualitative indicators of service delivery through direct citizen feedback. If they are widely disseminated amongst the public, together with budget information, they provide an opportunity for citizens to get involved in the budget allocation process, and to ensure that the budget addresses their needs.

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