Transition to programme budgeting in health in Burkina Faso: status of the reform and preliminary lessons for health financing

Hélène Barroy Françoise André Abdoulaye Nitiema TRANSITION TO PROGRAMME BUDGETING IN HEALTH IN BURKINA FASO: STATUS OF THE REFORM AND PRELIMINARY LESSONS FOR HEALTH FINANCING HEALTH FINANCING CASE STUDY No 11 BUDGETING IN HEALTH Hélène Barroy Françoise André Abdoulaye Nitiema TRANSITION TO PROGRAMME BUDGETING IN HEALTH IN BURKINA FASO: STATUS OF THE REFORM AND PRELIMINARY LESSONS FOR HEALTH FINANCING HEALTH FINANCING CASE STUDY No 11 BUDGETING IN HEALTH Transition to programme budgeting in health in Burkina Faso: Status of the reform and preliminary lessons for health financing / Helene Barroy, Françoise André, Abdoulaye Nitiema WHO/UHC/HGF/HEF/CaseStudy/18.11 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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Barroy H, André F, Nitiema A: Transition to programme budgeting in health in Burkina Faso: Status of the reform and preliminary lessons for health financing. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third- party-owned component in the work rests solely with the user. General disclaimers. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Printed in Switzerland. TABLE OF CONTENTS Acknowledgements ....................................................................................................................................................v Executive Summary ..................................................................................................................................................vi Introduction .................................................................................................................................................................1 1. Context of the reform ................................................................................................................................ 3 1.1 Changes to the subregional regulatory framework .................................................................. 3 1.2 Change to Burkina Faso’s legislative and regulatory framework ......................................... 5 1.3 Changes within the health financing system and alignment with public financial management reforms .......................................................................................................................... 7 2. Process of transition to the programme budget .......................................................................11 2.1 Programme budget: from preparation to institutionalization for all ministries (1998-2015) .........................................................................................................................11 2.2 The Ministry of Health’s transition to a programme budget: alignment with national health strategies ....................................................................................................... 14 2.3 Changing role of stakeholders in the reform .............................................................................16 3. Structure and content of the Ministry of Health’s budgetary programmes .............. 19 3.1 Structure of the Ministry of Health’s programme budget .................................................... 19 3.2 Analysis of the content of the Ministry of Health’s budgetary programmes ............... 20 3.3 Implications of the reform for specific health projects (immunization, HIV/AIDS, malaria, tuberculosis) .....................................................................................................23 4. First effects of the reform (2017-2018): progress and challenges .................................. 26 4.1 Moving towards an end to annual deferred budgetary programmes? ........................... 26 4.2 Towards more flexibility in spending? ..........................................................................................27 4.3 Towards financial accountability that is of benefit to the sector? ..................................... 30 Summary of progress, challenges and recommendations .............................................................. 31 Bibliography ................................................................................................................................................................33 Appendixes................................................................................................................................................................ 41 Appendix 1: Budget-planning process since the adoption of the programme budget .............. 41 Appendix 2: List of the Ministry of Health’s programme budget’s actions and activities ........ 42 Appendix 3: Variation in allocations by programme and action between 2017 and 2018 ........44 Appendix 4: Ministry of Health’s Budgetary programmes Performance Framework 2018-2020 .............................................................................................................45 List of tables Table 1: Summary of the WAEMU Harmonized Public Financial Management Framework .......4 Table 2: Key aspects of budget reform agenda in Burkina Faso ........................................................... 5 Table 3: Main items related to planning and implementation of reform plans and sector finance strategy ........................................................................................................................6 Table 4: List of purchasers and payment methods used..........................................................................8 Table 5: Health financing strategy: challenges and remedial action for public expenditure on health........................................................................................................................10 Table 6: Extract of the structure of the line budget, Ministry of Health (before 2017) ............... 15 Table 7. Alignment between the new budgetary programmes and the Ministry of Health’s reorganization (2018) .........................................................................................................17 Table 8: Ministry of Health’s programme budget’s programmes and actions (2018) ..................22 Table 9: Allocation of pre-reform and post-reform immunization expenditure ...........................24 Table 10: Actions and activities posted under the Presidency’s “Fight against HIV, AIDS and STDs” budget plan ...........................................................................................................25 Table 11: Budget allocation of malaria prevention and management expenditure in the programme budget (post-reform) .........................................................................................25 Table 12: Implementation of the health budgetary programmes (2017) ........................................... 28 Table 13: Extract from the Ministry of Health programme budget’s Performance Monitoring (2018-2020) ................................................................................................................... 29 List of figures Figure 1: History of the transition to the programme budget in Burkina Faso ............................... 12 Figure 2: Mapping of 2011 PNDS objectives, 2011-2018 Ministry of Health budgetary programmes and 2016 PNDS objectives .....................................................................................16 Figure 3: Structure of the Ministry of Health’s budgetary programmes in Burkina Faso .......... 20 Figure 4: Distribution of budget appropriations by programme in 2017 and 2018, Ministry of Health ................................................................................................................................27 v ACKNOWLEDGEMENTS The report was written by Hélène Barroy (WHO Governance and Health Financing Department), Françoise André (Public Financial Management consultant, WHO), and Abdoulaye Nitiema (Director, Studies and Statistics, Ministry of Health, Burkina Faso). It is the result of data collection and analysis work conducted by Hélène Barroy, Françoise André and Mathurin Koné (WHO consultant, public finance) in Burkina Faso between January and March 2018. Input was also provided by the WHO country office, in particular by Dr Alimata Diarra (Burkina Faso Representative), Dr Fatimata Zampaligré (health systems focal person), Dr Seydou Coulibaly (Intercountry Support Team, IST-WA) and Alexis Bigeard (Intercountry Support Team, IST-WA). We are grateful for their contributions. The authors would also like to thank the WHO African Regional Office, in particular Dr Grace Kabaniha, for their support in the successful conduct of the study. The analysis was performed in close collaboration with the Burkinabe government authorities. The authors wish to extend their heartfelt thanks to the following individuals from the Ministry of Health and the Ministry of the Economy, Finance and Development for their valuable technical contributions to this study: For the Ministry of Health: S.E. Dr Nicolas Méda, Minister of Health, Dr Hidnibba Francine Ouedraogo, Secretary general at the Ministry of Health, Dr Sylvain Dipama, Technical adviser at the Ministry of Health, Dr Isaie Medah, Director general of public health, Dr Samba Dialllo, Director general of health care provision, Dr Pierre Yameogo, Technical secretary of universal health coverage, Mr Daouda Akabi, Director of administration and finance, Dr Yacouba Sawadogo, Coordinator of the National malaria control programme and their teams. For the Ministry of Finance, Economy and Development: Ms Brigitte Compaore, Deputy director general of the budget, Mr Vincent de Paul Yameogo, Director of budget reform. The authors also wish to thank Fadhi Dkhimi (WHO) and Alexis Bigeard (WHO) who reviewed the report, as well as the local partners consulted during the conduct of the study, in particular the European Union (Bart Callawaert), WAEMU (Issa Sawadogo) and the World Bank (Bali Ouattara, Benoit Mathivet). The conclusion of this report were shared, discussed and formally revised by the authorities of the Ministry of Health of Burkina Faso during the seminar organised in Ouagadougou by the Ministry of Health and the WHO on programme-based budget in health on 11-12 July 2018. The study was funded with support from GAVI’s Sustainability Strategic Focus Area initiative and DFID’s Making Country Health Systems Stronger programme. vi BUDGETING IN HEALTH EXECUTIVE SUMMARY The critical role of budget formulation in optimising sector performance is often overlooked by many actors within the health sector. Determining the most effective allocation and flow of resources within the health system remains a central question for the public expenditure (and thus the performance) in this sector. Since the end of the 1990s, Burkina Faso (a French- speaking West African country) has initiated a profound reform relating to the management of public finances, in line with regulations set by the West African Economic and Monetary Union (WAEMU). One flagship measure within this reform was the introduction of a programme budget, marking a shift away from a purely input based budget. Institutionalizing this reform in Burkina Faso took twenty years, with the adoption by Parliament in 2017 of a budget presented according to a programme based approach - the first in the WAEMU region. The Ministry of Health was one of the first pilot ministries to engage in this reform and achieve the transition to institutionalization, by consolidating a budget around three major budget programmes that aligned with the National Health Plan, i.e. the Plan National de Développement Sanitaire (PNDS). Burkina Faso‘s shift to a programme budget for health offers interesting lessons for other countries engaged in similar reforms. In particular, by studying the process and impact of this reform, we highlight the following elements related to the definition and effective implementation of the programme budget in the health sector: Defining the content of budgetary programmes is a central issue for the health sector. Harmonizing budgetary programme content with the sector’s priorities requires strong mobilization of sectoral actors in coordination with financial actors, in order to define the first budgetary programmes and their subsequent periodic reviews; The programmatic budget formulation reduces financial fragmentation resulting from previous input budgeting, and also creates scope to further reduce financing duplication and fragmentation by integrating “disease” interventions into broader budgetary programmes; To be complete, the reform involves a transition process across several levels. Along with reforms relating directly to public finance, legal aspects (such as updating the regulatory framework) as well as institutional aspects (such as strengthening sectoral capacities in budgetary planning) should be addressed with priority; The reform goes beyond a change in budget formulation by requiring improved expenditure management. It also lays the foundations for more flexible spending that can be adapted to sector changes when needed, and allows for reallocation within budget programmes; When accompanied by a quality performance monitoring framework, the programme budget makes it possible to set up performance monitoring, combining financial/budgetary and operational/programmatic aspects in a single framework. If policy makers use the performance information, a unique opportunity to guide future budget decisions in an efficient manner arises. While Burkina Faso is advanced in budget programme implementation, particularly in the health sector, some challenges remain. In 2018, the Ministry of Health rightly initiated a review of the content and contours of the two main budget programmes, in order to bring them into line with vii the department’s new strategic directions and to improve their overall quality. The definition of a more relevant performance-monitoring framework is also a key aspect to be strengthened. In parallel, building the capacity of newly appointed Programme Directors and their teams in programme budgeting seems essential for ensuring better involvement in programme definition, and thus coherence in their implementation. Strengthening the links between budget reform and health financing strategy, notably the creation of the Health Insurance Scheme (RAMU), also needs close monitoring by decision-makers in order to ensure coherence and coordination. 1IntroductIon INTRODUCTION Most countries around the world have begun a transition to programme or objective- based budgets to improve their alignment with public policy priorities and to meet the need for accountability and transparency expressed by many parliaments and citizens.1 In addition to changes in the presentation of budget documents, this reform involves major changes in the budgeting and expenditure management system requiring closer collaboration between finance and line ministries. In the health sector in particular, it is not easy to identify the outlines and content of budgetary programmes. While this reform has the potential to improve the organising of funds according to sector priorities/ objectives, it requires the health authorities’ consideration during the preparation phase so that it may deliver the expected benefits to the sector. Development partners, including those involved in the health sector, are also relatively unaware of this transition and a better understanding of its implications is needed. Against this background, in 2018, the World Health Organization’s (WHO) Department of Health Systems Governance and Financing began a work programme on health budget structure issues to produce more information on the process and the effects of health budget reform and to offer more support to countries undergoing reform. This work programme is divided into three principal areas: 1. A global review of health budget structures; 2. Case studies on the transition to programme budgets in the health sector; 3. Training and support for health budget reform.2 Burkina Faso was identified as one of the first countries to be studied in the WHO African Region. Having completed a pilot phase, Burkina Faso was the first WAEMU country to have institutionalized programme budgets, i.e. a budget created for all the ministries in 2017 around major public policy objectives and priorities. Having made progress with this transition, WHO has chosen Burkina Faso for this study to identify the preliminary lessons learnt from the experiment and to share these lessons with other countries in the subregion and beyond. The study’s specific goals were to analyse the structure of the health budget before and after the reform; to document the process of transition from a line budget to a programme budget, focusing on specific projects such as immunization; to analyse the initial effects of the reforms from a sector perspective; and to identify useful recommendations for any changes to the country’s reforms. The study began with a document review, including of the literature and budgetary and legal documents, followed by data collection in the country and interviews with key stakeholders in the health and finance sectors between January and March 2018. The results were shared with the Ministry of Health authorities in May 2018 and reviewed and approved in July 2018. The report begins with a contextual review of the developments in the WAEMU regulatory framework and its transposition into national law with respect to the programme budget and public financial management more generally. A review is also conducted of the 2 BUDGETING IN HEALTH developments in health financing and their links to public finance. The second part of the study report focuses on the budget reform process, analysing the various stages in the transition, including in the health sector, and the various players’ roles in the reform. The third part deals more specifically with the structure and content of the Ministry of Health’s three budgetary programmes and, at the request of the partners supporting and involved in this study, contains an analysis of the implications of the reform with respect to the inclusion of specific interventions – such as immunization, HIV/AIDS, malaria, tuberculosis – in the new budget formulation. The last section of the report analyses the initial impact of the reform on budget planning, flexibility in managing expenditure and accountability. The study concludes with a summary of the progress and challenges of the reform and highlights some key recommendations on adapting the reform to best address the needs of the sector in Burkina Faso. 3context of the reform In 2009, following discussions that had been held since the early 2000s, the West African Economic and Monetary Union (WAEMU) agreed to a harmonized public finance framework applicable to all its member states. Some of this reform’s flagship measures included introducing results-based management and a programme budget tool. Having transposed the whole regulatory and legislative framework required by WAEMU into its own legislation between 2013 and 2016, Burkina Faso adopted the first “programme budget” in 2017.I It was therefore the first WAEMU country to shift to this approach. At the same time, certain aspects of the discussions that had been initiated on health financing and its considerable implications for public financing levels and streams, were conceived in conjunction with public financial management reforms. 1.1 CHANGES TO THE SUBREGIONAL REGULATORY FRAMEWORK In 2009, the WAEMU countries adapted the Harmonized Public Financial Management Framework drafted in the late 1990s to international standards and best practice in public financial management. In 2009, the I In Burkina Faso, the word “programme budget” has officially been adopted and will be used in the rest of this report. WAEMU Council of Ministers adopted six directives (Table 1). The aim of this new regulatory framework was to ensure better outcomes and more effective public policies. It laid down new rules on modernizing budgetary management and introduced budgetary discipline that facilitated sustainable budgetary policies and more efficient public resources, set within a framework of major budgetary constraints. It also aimed to strengthen the link between national development strategies, sector policies and the state budget. Finally, it established a results-based culture by giving the “operational” staff responsibility for the results achieved and introducing greater clarity, transparency and effective accountability in the management of public affairs. The transition to a programme budget is one of the key elements of the WAEMU Finance Law Directive (No. 06/2009). In Section III, Article 12, “Content of the year’s finance laws”, the directive specifies that “within ministries, appropriations are broken down into programmes[...].” The article defines a programme as “consolidating the appropriations set aside to implement an action or a coherent set of measures that represent a clearly defined medium- term public policy.” These programmes are combined with “specific goals, agreed on the basis of public interest and expected outcomes.” These outcomes, “measured by performance indicators, are regularly evaluated and embodied in an [annual] performance report.” 1. CONTEXT OF THE REFORM 4 BUDGETING IN HEALTH Transcribing the Directives into national law varies according to the state and directive. The WAEMU member states had committed to transposing the directives into their national legislation in December 2011, with a deadline of January 2017 for full implementation of the programme budget provisions. Following a decision of the WAEMU Council of Ministers in April 2017, this deadline was extended to 1 January 2019.II II Press release of the Ordinary Session of the Council of Ministers of the Union, Dakar, 31 March 2017 “The Council examined the status of implementation of the Directives of the Harmonized Public Financial Management Framework on 31 December 2016 (...). With respect to the states’ implementation of these reforms, the Council invited the Ministers of Finance to complete the implementation of the directives and in particular the implementation of the programme budget by 1 January 2019 at the latest.” However, national decisions appear to have set other extensions. In December 2016, Senegal’s National Assembly therefore voted to postpone the date the Institutional act on finance laws will come into effect to 1 January 2020. While Burkina Faso was among the first of the member states to transpose the Transparency Code (after Senegal, which did so in December 2012), it was the last to do so for the Finance Law and the decrees pursuant to it. Even though other countries have indeed amended their regulatory framework more swiftly, implementation is very uneven between states. By the end of 2016, only Burkina Faso had decided to adopt a budget according to the programme-budget format for the 2017 fiscal year, in line with the deadline initially set by WAEMU. For 2017, the other member states had planned implementation in some ministries (Benin, Côte d’Ivoire, Mali and Senegal) or future implementation in the state budget (2018 in Niger or 2019 in Togo).4 Table 1: Summary of the WAEMU Harmonized Public Financial Management Framework Directives of the WAEMU Harmonized Public Financial Management Framework Main guidelines of the Directives Directive No. 01/2009/CM/WAEMU of 27 March 2009 on the Code of transparency in public financial management in WAEMU General umbrella directive for five others, which establishes the principles and obligations that the member states must respect on managing government and other government departments’ funds in their legislation and practice. Directive No. 06/2009/CM/WAEMU on Finance laws in WAEMU Sets out the rules on the scope and classification of the Finance laws, their content, presentation, macroeconomic framework, preparation and votes, as well as the implementation and checks on the Finance laws and, finally, the transitional provisions. Directive No. 07/2009/CM/WAEMU on the General regulations on public accounting in WAEMU Sets out the rules governing the management of public accounts, securities or assets. Directive No. 08/2009/CM/WAEMU on the government budget classification in WAEMU Sets out the basic rules and principles for presenting budget operations. Directive No. 09/2009/CM/WAEMU on the government chart of accounts in WAEMU Lays down the basic rules for the accounting of financial and budget operations in the member states. It determines the aim of the general accounting, the standards, rules and procedures on keeping and producing the state’s accounts and financial statements. Directive No. 10/2009/CM/WAEMU on the government financial operations table in WAEMU Specifies the general principles on the drafting and joint presentation of statistics on the state’s financial operations that form the basis of multilateral monitoring. Source: WAEMU, 2009 5context of the reform 1.2 CHANGE TO BURKINA FASO’S LEGISLATIVE AND REGULATORY FRAMEWORK Burkina Faso has made a considerable effort to update and strengthen its legislative and regulatory framework on public finance. All laws and decrees were adopted between 2009 and 2015-2016, providing a complete and up-to-date regulatory framework for WAEMU directives (Table 2). The adoption of this regulatory framework, brought into line with the 2009 WAEMU Directives, follows on from the comprehensive approach initiated in the country in the early 2000s. As soon as the Plan of action to strengthen budget management was drafted and adopted in July 2002, Burkina Faso began a process of reform and modernization of its budgetary systems based on a results- based management (RBM) approach. This commitment is reflected in the Strategy to strengthen public finance, adopted in April 2007 and in the Economic and financial sector policy for 2011-2020 (see Table 3). The guidelines on results-based management are laid down within these frameworks. To improve the planning of resources, from 2001, the authorities introduced the Medium- Term Expenditure Framework (MTEF) setting out budget allocations (“envelopes”) for each ministry by inputs (e.g. operations, personnel, goods and services, and transfers).III The MTEF is updated every year to follow the macroeconomic forecasts as closely as possible. III The goals of the global MTEF are: (1) to define a coherent and realistic multi-year resource framework based on an accurate macroeconomic framework, (2) to identify medium-term sectoral financial budgets aligned with the Government’s strategic priorities and budgetary constraints, and (3) to ensure a predictable financial framework for ministries to develop and implement strategies and achieve the expected results. Table 2: Key aspects of budget reform agenda in Burkina Faso Directives of the WAEMU Harmonized Public Financial Management Framework Burkina Faso – National legislative and regulatory transposition Directive No. 01/2009/CM/WAEMU on the Code of transparency in public financial management in WAEMU Law No. 008-2013/AN of 23 April 2013 on the general code of transparency in public financial management in Burkina Faso Directive No. 06/2009/CM/WAEMU on Finance laws in WAEMU Institutional act No. 073-2015/CNT of 06 November 2015 on finance laws, which came into effect on 1 January 2016 Directive No. 07/2009/CM/WAEMU on the general public accounting regulations in WAEMU Decree No. 2016-598/PRES/PM/MINEFID of 08 July 2016 on general public accounting regulations Directive No. 08/2009/CM/WAEMU on the government budget classification in WAEMU Decree No. 2016-600/PRES/PM/MINEFID of 08 July 2016 on the government budget classification Directive No. 09/2009/CM/WAEMU on the government chart of accounts in WAEMU Decree No. 2016-601/PRES/PM/MINEFID of 08 July 2016 on the conceptual framework for public sector accounting Directive No. 10/2009/CM/WAEMU on the government financial operations table in WAEMU Decree No. 2016-602/PRES/PM/MINEFID of 08 July 2016 on the government financial operations table Source: WAEMU, 2009 and Burkina Faso, www.legiburkina.bf5 6 BUDGETING IN HEALTH In addition to changes that affect budget planning, public finance reforms have an impact on expenditure practices, namely by introducing the principle of “decentralizing authorization” (Article 70, Institutional act on finance laws – LOLF). This approach translates into a transfer of certain prerogatives from the Minister of Finance, previously the sole primary authorizing officer, to the sector ministers (and thus the Health Minister), who become the chief authorizing officers for their ministries’ appropriations. The sector minister therefore has direct responsibility for their ministry’s expenditure as they proceed with the respective commitments (authorize expenditure) and settlement (approve payment) of the appropriations. The ministers who authorize spending can then delegate their powers within the Ministry (Article 67), and specifically to programme managers for appropriation commitments.IV Besides decentralizing the authority to authorize expenditure, the sector ministries are now responsible for various controls that IV In the Ministry of Health, the commitment is delegated to the Department of financial affairs (DAF) and may subsequently be transferred to the programme managers; the “Cellule d’ordonnancement” is responsible for the authorizing (currently still within the Ministry of the Economy, Finance and Development but which will be transferred to the sector ministry). Table 3: Main items related to planning and implementation of reform plans and sector finance strategy Plan of action to strengthen budget management 2002-2006 Strategy to Strengthen Public Finance 2007-2015 Economic and financial sector policy 2011-2020 Budget planning Strengthen the quality and transparency of the Finance Law (with an emphasis on frameworks for medium-term expenditure and results-based management (RBM)) - Transparent and efficient public expenditure management process - Plan expenditure according to the strategic allocation principle and results-based budgeting - Strengthen stakeholder accountability - Results-Based Management and introduction of Programme Budget approach - Strengthen consistency of the macroeconomic framework, medium-term fiscal plans and budget allocations - Adjust tools to the Results-Based Management approach and the Programme Budget - Support in sector public policy-making - Bring the legislative and regulatory framework in line with WAEMU directives - Capacity building of budget management stakeholders according to the PB approach Budget implemen- tation Strengthen the monitoring of budget implementation (system and data) - Transparent and efficient public expenditure management process - Strengthen stakeholder accountability - Complete and reliable budget implementation data - Develop statistical output - Adjust the I.T. system to the PB - Improve the spending flow by creating verification units in sector ministries along with the flow in terms of procedure and participants Controls Strengthen controls on the implementation of the budget Efficient monitoring system aligned with international standards Consideration/further development of the monitoring system in principle and adjusting it to PB requirements Sources: Plan of action to strengthen budget management and Strategy to strengthen public finance from “Evaluation of Public Financial Management Reform in Burkina Faso, 2001–2010, DANIDA, Final Country Case Study Report, June 2012”6; Economic and financial sector policy: Ministry of the Economy and Finance, Economic and Financial Sector Policy 2011-2020, Economic and financial sector policy 2011-2020, April 20117 7context of the reform will take place at different stages in the chain of expenditure. Government expenditure verification unitsV were set up in the ministries in 2012 to free up the central monitoring departments, reduce the time taken to authorize the expenditure and also to support the decentralization of authorizations and the development of authorizing officers’ and their teams’ responsibilities.VI The other principle governing public expenditure is the principle of “asymmetric fungibility” introduced in Burkina Faso by the institutional act of 2015. According to this principle, spending, can vary upwards or downwards, within each budgetary programme ceiling. Wage expenditure, remains under control: it can only fall (not rise), while capital expenditure can only rise, hence the “asymmetry”. This principle is supposed to apply to each budgetary programme, providing a larger autonomy to the Ministry, but somehow contradicts a programme model that would enable full flexibility on all items of expenditure within the same programme.VII V The units are responsible for verifying and validating the expenditure, from the administrative phase through to the payment; a verification unit is made up of a “Financial Check” cell, an “Authorizations” cell and a “Payments” cell, which are hierarchically and operationally linked to the parent organization, namely the Ministry of the Economy, Finance and Development’s Office of public procurement and financial commitments, Office for scheduling and accounting and Public accounting office and treasury respectively. VI In accordance with the WAEMU directive, the LOLF enshrines the increased powers of the Minister of Finance through regulatory powers, which enables them to maintain the budgetary and financial balance stipulated in the current Finance Act, cancel appropriations and make the authorizing officers’ use of appropriations subject to the availability of cash (Art. 69). VII Fungibility (LOLF, Art. 17, section 2): “... within the same programme, the authorizing officers may amend the type of current appropriations and use them, if they are free to do so, in the following cases: – staff appropriations to increase appropriations for goods and services, transfer or investment line items; – appropriations for goods and services and transfers to increase investment appropriations.” 1.3 CHANGES WITHIN THE HEALTH FINANCING SYSTEM AND ALIGNMENT WITH PUBLIC FINANCIAL MANAGEMENT REFORMS Along with reforms to public financial management, in 2010, the country began a review aimed at changing the health financing system. Between 2013 and 2017, the Ministry of Health developed a health financing strategy (2017-2030)8, which was presented to the Council of Ministers in June 2017.VIII In 2015, public and external funds accounted for 33% and 22% of total current health expenditure respectively9. Between 2015 and 2016 though, the share of direct payments went down from 36% to 31% of total health expenditure, a noticeable decrease most likely attributable to the user fee removal policy. Half of public expenditure is financed by external funds (on average 47% of public health expenditure between 2012 and 2015). In absolute terms, budgetary provisions have nearly quadrupled in 10 years, rising from around 34 billion CFA francs in 2005 to 132 billion in 2014 (and 180 billion in 2016). As a share of total public expenditure, health expenditure remained relatively stable between 2012 and 2015, averaging 12% over the period. Burkina Faso is one of the countries in the African region that has VIII The financing strategy (October 2017 version) is available but has not been formally adopted by the Government. Following a review by the Council of Ministers, the hope is to develop an operational plan based on this strategy, enabling progress to be made towards concrete implementation. In November 2018, the operational plan was finalized and submitted to the Cabinet for approval. 8 BUDGETING IN HEALTH historically given high priority to the health sector in its public spending. In the past, the health financing system has been characterized by highly fragmented funding systems. Mapping conducted in 201410 shows around 30 schemes, most of which are attributable to the free programmes set up since 2006. Two funds cover a very limited range of health services for employees in the formal private sector (National social security fund – CNSS) and civil servants (Civil servants’ pension fund – CARFO)IX. According to a 2011 study, community-based health insurance in Burkina Faso comprises around IX CNSS package includes : maternal and child health services, HIV/Aids treatment and sanitary evacuation for treatment abroad. CARFO extended coverage in 2009 to provide medical and surgical assistance, and care and treatment in case of work accidents. 200 entities, of which 188 are in operation.X These “mutuelles” cover a total of 140,000 beneficiaries (fewer than 1,000 beneficiaries per entity), and the services that are covered are generally part of the minimum and complementary health care package in first and second-level health facilities. The payment system for health services encompasses a range of methods, due on the one hand to the fragmentation of the schemes and on the other to the use of multiple payment systems for the same scheme. The table below, drawn up as part of the WHO X According to a 2011 study, these include 131 community- based health insurance (“mutuelles”), 38 professional “mutuelles”, 22 other cost-sharing schemes, 9 other prepayment schemes and 5 village solidarity funds (ASMADE. Inventory of mutual societies for universal health coverage in Burkina Faso, October 2011)11. Table 4: List of purchasers and payment methods used Overall budget allocation Allocation by budget item Payment by procedure Payment on a case-by- case basis (flat rate) Capitation Payment by results Ministry of Health – DAF X X       Ministry of Health – Health development programme X X X Ministry of the Economy, Finance and Development/Ministry of Territorial Administration and Decentralization/Ministry of Health X Generic medicines purchasing agency           X National council for the fight against HIV/AIDS and sexually- transmitted infections X NGO X X X X     Mutual health insurance X Private insurance     X       Universal health insurance scheme       X  X   TFPs (regulated) X X Source: WHO, 201712 9context of the reform study on payment for health services, maps the various existing mechanisms.12 The overall goal of the new health financing strategy is to “remove barriers to access to health care.” To achieve this, it lists 17 key measures to address the challenges that have been identified. One of the key measures is the implementation of a universal health insurance scheme – RAMU, which still needs to be outlined. This would be a mandatory pre-financing system, subsidized with public funds. Coverage of the formal public and private sector is identified as a priority; the informal sector is planned to be covered through community-based health insurance schemes, although the terms have yet to be defined. Another key issue being discussed pertains to aligning the RAMU with existing funding systems, particularly those for free care programmes, which could be incorporated in the universal health insurance scheme. Many of the challenges identified in the health financing strategy and the associated arrangements relate to improved management of public resources in the sector, with a clear link being drawn to reforms in the management of public finance. The strategy also identifies the implementation of Results-Based Management, and the programme budget, as a tool for improved “oversight/governance/monitoring of the sector’s financing system” (see Table 5). This alignment between public finance and health financing reform must be highlighted as positive. Another reform – decentralization – is linked to the public financial management reforms and directly affects the health sector. The reform, which began in 200413 provides for the transfer of skills and resources from the state to the municipalities for level 1 facilities (health centres – Centre de Santé et de Promotion Sociale)14, while the regions are assigned jurisdiction over health centres with surgical units,15 corresponding to level 2. This involves a transfer of skills to build and comprehensively manage these health facilities, including the staff, for minimum (first level) and complementary (second- level) packages. This reform has several implications from a sector financing point of view. The transition to the programme budget involves grouping two types of transfers for the municipalities under a single government “transfer of resources to local and regional authorities” programme and “transfer to the health sector” action. The Ministry of Health in principle no longer manages the subsidies to operate and invest in first-level health facilities.XI In practice, however, only skills, and therefore resources, are transferred to the municipalities as there is no transfer to the regions. The human resources associated with the delivery of minimum and complementary care packages should also be transferred to lower levels, but this part of the policy has not been implemented to date, owing to resistance from the Ministry’s staff, currently part of the civil service. Discussions have been under way since 2017, with plans to create a hospital XI These funds are subject to two interministerial orders (Ministry of the Economy, Finance and Development/ Ministry in charge of decentralization and Ministry of Health) on the allocation of transferred financial resources, and orders drafted by the Ministry of Health DAF (based on the Directorate general of sector studies and statistics proposals), prior to being sent to the Ministry of the Economy, Finance and Development’s General directorate for regional development (DGDT) for their operational implementation and transfers at the start of the year. One relates to funds earmarked for investments in buildings to standardize basic health facilities and the other, sums intended for recurring costs in basic health facilities. 10 BUDGETING IN HEALTH public service, a body separate from the national civil service, but which all the jobs in health facilities could be linked to. Under the programme budget, staff costs are charged to the Ministry of Health’s various programmes (see section 4.2) but are still implemented, for remuneration, by the Ministry of the Economy, Finance and Development. Table 5: Health financing strategy: challenges and remedial action for public expenditure on health Task Challenges Measures Mobilizing resources Capacity of the Ministry of Public Health to monitor the overall health budget System for mobilizing and monitoring financial flows for the whole sector Ensure appropriate financing of the sector Allocate 12% of the health budget Ensure financing of the various schemes, possibly subsidized (universal health insurance scheme and free schemes) Universal health insurance scheme subsidy plan Pooling resources/strategic purchasing Implement decentralization Municipal financing plan Optimize and align appropriations centrally Delegated appropriation targeting plan Allocation of appropriations Set up a strategic purchasing team Oversight/governance/ monitoring Alignment between planning and financing needs Results-based management (programme budget) Actual availability of financial resources in health facilities and flexibility in managing funds Review of provisions related to health facilities’ use of resources Source: Health Financing Strategy, Ministry of Health, 201710 11Process of transItIon to the Programme budget A transition process that lasted almost two decades led to a programme budget being institutionalized and adopted by the Parliament of Burkina Faso in 2017. For the health sector, the long phase of preparation and oversight (1998-2015) enabled a favourable technical, legal and institutional environment to be established. During this period, a programme budget was prepared specifically for the Ministry of Health, to complement the input line budget, and the objectives/programmes were aligned with the 2011-2020 National Health Development Plan. In 2018, under the leadership of a new Minister, the Ministry of Health began a process of reformulating the health sector budgetary programmes to bring them more in line with a new vision for the sector, placing prevention and universal access to services at the core. During the process, the Ministry of Health took ownership of the reform, seeing an opportunity for better alignment between the budget and the sector’s priorities. 2.1 PROGRAMME BUDGET: FROM PREPARATION TO INSTITUTIONALIZATION FOR ALL MINISTRIES (1998-2015) The programme budget approach was first introduced in Burkina Faso in 1997.16 From 1998, six pilot ministries, including health, were identified for implementation of the programme budget. In 2000, the approach was extended to all ministries and institutions who were now required to prepare a programme budget alongside/in addition to their line budgets. However, in the absence of suitable reference systems and frameworks until approximately 2005, there was little consistency in the documents being prepared. From 2005, the country worked to frame and formalize the process, which was expedited in 2010. Closer oversight was implemented by creating different governance entities within the Ministry of Finance with contacts in the sector ministries. The technical framework was also developed by producing benchmarks that offered guidance on preparing programme budgets, particularly in the six ministries previously identified as pilots. From 2010 to 2016, the country entered a pre-institutionalization phase with the aim of meeting the deadlines set by WAEMU (initially planned transition in 2017). As mentioned above (section 1), the legislative and regulatory framework was updated between 2013 and 2016. The regulations, in line with international recommendations, include accurate information on the number and structure of the budgetary programmes (a maximum of 7 programmes, 10 actions per programme and 40 activities per action in each ministry).17 Support for sector ministries has been accelerated through training, along with adjustments to expenditure management and monitoring tools (See Box 1). Immediately after the 2016 presidential circular that instructed a shift in the 2017 2. PROCESS OF TRANSITION TO THE PROGRAMME BUDGET 12 BUDGETING IN HEALTH budget law was adopted, the programme budget became mandatory and was the only budget presented for all the ministries in 2017. The Budget law adopted by Parliament in 2017 is set out according to 127 programmes and provisions for the 39 ministerial departments and institutions.XII XII The appropriations not allocated to programmes were divided into provisions, comprising a set of appropriations to cover expenditure that could not be directly linked to public policy objectives (Institutional act, Art. 16). Figure 1: History of the transition to the programme budget in Burkina Faso Source : Authors 1998: launch of the programme budget as an exercise for pilot ministries 2010-2015: strengthening the technical, legislative and institutional environment 2017: first official programme budget adopted by Parliament Activity 2016: Presidential memorandum officially establishing the programme budget in 2017 2000-2005: expanding the programme budget to all ministries INSTITUTIONALISATIONPREPARATION 2018: review of the programme budget content by the Ministry of Health 2020: complete review of the programme budget content planned for all the Ministries 13Process of transItIon to the Programme budget XIII (1) Policy document for the implementation of a Programme Budget in Burkina Faso, June 2010 (adopted by the Council of Ministers in June 2010); (2) “Programme budget implementation strategy” (approved by the government programme budget in June 2011 and adopted by the Council of Ministers in February 2012) supported by an action plan; (3) two methodology guides (a) to prepare the programme budget and (b) to monitor/evaluate the process in the ministries (adopted by the Council of Ministers in 2010 and 2011 respectively); (3) design of several mock-ups/outline for the ministerial “programme budget” document. XIV Order No. 2009-477/MEF/CAB of 29 December 2009 on the setting-up, roles, composition and running of the Steering committee for the government programme budget and Order No. 2009-484/MEF/CAB of 29 December 2009 on the Unit to set up the government programme budget. XV Their aims were to provide guidance, to stimulate and supervise the process and finally, to lead the work to be performed on incorporating the WAEMU directives into the finance laws. The Steering Committee for the government programme budget and the Technical secretariat of the Steering Committee for the government programme budget were established by decree in September 2010. XVI Their roles were (i) to work with the Ministry of Finance to contribute to the drafting or re-reading/transposition of the sector policy into a programme; (ii) to work with the Ministry of Finance to lead the process of drafting and monitoring the implementation of their ministry or institution’s programme budget and (iii) to participate in the implementation of any activity contributing to the drafting of the government’s programme budget. XVII The Integrated Expenditure System (CID) has been adjusted to the programme approach. The budget planning module for the information system was therefore deployed to ensure the 2017 draft budget could be prepared, and that the system could include all the tables using the programme approach and in accordance with the LOLF. Technical guidance: production and gradual revision of standards and tools (guidance document for the implementation of the 2010 programme budget), programme- budget implementation strategy (2011), methodology guides (2010 and 2011),XIII outline, work on dividing public policies into budgetary programmes (2010-2011), setting out annual performance plans (from 2011 onwards), guide for programme-budget execution (2017) Governance: setting up governance of the reform involving finance and the sectors (budget planning reform committee (2008), steering committee for the implementation of the programme budget (from 2009)XIV with implementation teams in each ministryXV and the creation of ministerial technical units for the programme budgetXVI) Adapting the management tools: adapting financial information systems to the new approach (review of the Integrated Expenditure System – CID)XVII Capacity building: producing a capacity-building plan for stakeholders, including in the sectors (2013), with the exception of programme officers (from the Ministry of Health) appointed after the training. Capacity building activities targeted at the financial responsible officers, and not the operational arm of the reform (e.g., budgetary programme directors). Legal framework: Suitable legal and regulatory framework, including the transposition of WAEMU directives (2013-2016) Adoption of a presidential circular in 2016 for official transition to the programme budget in all ministries. Box 1: Key factors for programme budget institutionalization in Burkina Faso 14 BUDGETING IN HEALTH 2.2 THE MINISTRY OF HEALTH’S TRANSITION TO A PROGRAMME BUDGET: ALIGNMENT WITH NATIONAL HEALTH STRATEGIES Historically, up to and including 2016, the Ministry of Health’s budget was an input or line budget. The budget was presented by type of expenditure, essentially based on four main categories (heading) and then broken down by economic classification (article, section, paragraphe) (Table 6). The budget was very detailed (up to paragraph level). For example, the budget was presented and reported to item level, i.e. for health, “fuel”, “office supplies” and “maintenance products” came under “operating expenditure” (Heading 3) (Table 6). From a sector point of view, this structure had several disadvantages: 1) expenditure was broken down into categories that were unrelated to the sector’s objectives and activities; 2) there was a lack of flexibility when reallocating between different itemsXVIII; 3) the reporting, although very detailed and burdensome, was limited and did not provide information on the sector’s actual performance. The Ministry of Health, a pilot ministry since 1998, has gradually worked on the transition to a programme budget. After a decade of trials and adjustments between 1998 and 2009, in 2010 the line budget was transposed to a programme budget. According to those in charge of the Department of studies and planning (now the Directorate general of XVIII The absence of flexibility belongs more to an expenditure management issue than a purely budget formulation and presentation challenge. However, since expenditure management is often aligned on budget formulation, budgets that are formulated by inputs are generally associated with lack of flexibility in the use of resources. sector studies and statistics), the Ministry sees this as the main advantage of “increased alignment between allocations and sector priorities.” The Ministry’s initial proposal in 2010 was built around 5 programmes and 24 actions, aligned with the strategic focus of the PNDS 2011-2020 (developed in 2010) and its 24 focus areas. Following discussions with the Ministry of Finance, a consensus finally emerged around a smaller group of three programmes: 1) access to services; 2) health services provision; 3) oversight and 24 actions. Future budgets pilots up to 2016 will be developed on this basis and then formalized from 2017 with some marginal modifications to the number and drafting of the actions (26 in 2017, 21 in 2018) and activities. When the 2011 programme budget was developed, it appears that a special effort was made to ensure consistency between the budget formulation and the National Health Development Plan, to pave the way for greater alignment between the expenditure and the sector’s needs. It is possible to map to map PNDS’s strategic objectives and budgetary programmes and identify obvious pathways (Figure 2). In the years following 2011, the same model was used to prepare the Ministry of Health’s budgetary programmes. The same formulation was used in the budgets from 2013 to 2016. During the review of the PNDS 2016-2020 (second phase), it was decided to align this Plan’s new strategic objectives on the presentation of the three budgetary programmes which now mirror one another (Figure 2). Since 2018, the budgetary programmes have needed to be redefined to bring them more in 15Process of transItIon to the Programme budget line with the sector’s vision championed by the Minister who took up the post in February 2017. Responding to the wish to have “a national health system that values prevention and makes the community-based approach to primary health care the foundation of Burkina Faso’s move towards universal health coverage”XIX, the new intended budgetary formulation is the following: 1) a national public health programme (covering prevention, promotion and health security); 2) a national programme of health care provision (and access to health products) that targets curative care; 3) a national programme of governance of the health system. However, this formulation has XIX Presentation by Prof. Nicolas Méda, Minister of Health: Vision, reorganization, priorities and response strategies, 2018, not been adopted for the official 2018 budget, and it is expected that the formal review will not take place before 2020 when the Ministry of Finance has scheduled a review of all budgetary programmes (Table 7). Expecting the official revision, for the project of finance law 2019, the ministry proposed the following formulation: 1) Access/Purchase of health care; 2) Provision of services/ public health; 3) Governance/Stewardship. This transitional approach was chosen in order to not overthrow the delivery of the operationnal content – which is identical to the 2018 budget. However, this creates an important confusion between the name and the outputs of the programmes. For example, under the programme «Provision of services/ public health», most actions are a matter of Table 6: Extract of the structure of the line budget, Ministry of Health (before 2017) Heading Chapter Article, section, paragraph Heading 3. Operating expenses Cabinet/General Secretariat/Departments Regional health directorates Health districts* Purchase of goods and services (article) – supplies (section) . fuel, office supplies, maintenance products, etc. (paragraph) . vaccines, specific supplies – expenditure on care/maintenance . building, vehicle, etc. – service provision . security costs, etc. . gas – others . meetings, travel, etc. . food, medicines, reagents, travel Heading 4. Current transfer expenditure Public establishments: university/regional hospitals National Centres Programmes/specific activities (diseases, free of charge/subsidies, national immunization days (NID), contributions to organizations, etc.) Interns/specialist doctors Operating Grants – subsidies to public institutions . salary, equipment, materials, medical care (public establishments, university/regional hospitals) – grants to beneficiary categories . support for activities (programme, specific actions) Other current transfers . contribution to organizations . internal allowances/bursaries Note: Health district: functioning of the district core team and provisions for medical centres with a surgical unit. Source: Budget 2016. 16 BUDGETING IN HEALTH provision (former name of this programme). To solve this problem, the Ministry of Health committed to work again on the content of programmes between 2019 and 2020, in order to propose a more coherent framework in 2020-2021 during the official revision. 2.3 CHANGING ROLE OF STAKEHOLDERS IN THE REFORM The Ministry of Finance managed the reform process with support from the International Monetary Fund (IMF). The transition to a programme budget was part of a deeper reform of modernizing public finance, mainly affecting the finance sector. The pressure from WAEMU with a 2017 deadline to introduce programme budgets in the subregion encouraged major investment, STRATEGIC GOALS OF THE PNDS 2011 BUDGETARY PROGRAMMES FOR HEALTH 2011-2018 STRATEGIC GOALS OF THE PNDS 2016 Figure 2: Mapping of 2011 PNDS objectives, 2011-2018 Ministry of Health budgetary programmes and 2016 PNDS objectives Increasing health financing and improving the affordability of health services Promoting health research Improving the management of the health information system Developing infrastructure, equipment and health products Promoting health and the fight against disease Developing human resources for health Improving health service delivery Developing leadership and governance in the health sector Access to health services Health service delivery Oversight and support for Ministry services Access to health services Health service delivery Oversight and support for Ministry services 17Process of transItIon to the Programme budget which was a reason for the heads of state to push the reform through. Soon, from 1998, by making sectors such as health or education pilot ministries for the reform, a dialogue was established between the finance and other sectors. The issue of alignment between the budget and the PNDS, which was key for the Ministry of Health, underlay the Ministry of Health’s increased engagement, which began in 2010. This was a critical issue from a sector planning perspective and was consolidated in 2010 with the development of the PNDS 2011-2020. The dialogue was framed by various joint committees, led by finance, but with the participation of players in the health sector (mainly the Department of studies and planning). The first to be involved in the Ministry of Health were individuals working on strategic planning. In 2010 (and so until 2016), the Department of studies and planning (now the Directorate general of sector studies and statistics) was responsible for formulating the consolidated budget around three programmes. The personal comitment of the director of the Directorate general of sector studies and statistics, who was convinced of the interest of such a reform for the sector, has been an important factor for the progress of this process. The technical directorates and lower administrative levels (e.g. for the sector: districts, health facilities, etc.) however, seemed less involved. It appears that a bottom-up approach was not followed, explained by the fact that the PNDS, the framework document developed in consultation with all the stakeholders in the sector, formed the basis for formulating budgetary programmes. A change of organization and of the organization chart of the Ministry of Health in June 2018 allowed the emergence of two large general directorates namely in charge of the two first budgetary programmes (Table 7). Aligning the Ministry’s new organization with the programmes in 2018XX appears to be a positive factor in successful institutionalization. The Directorate General for Public Health is expected to take the lead on the “new” public health budgetary programme (formerly, “access to health services”), while the Directorate General for Health Care and Health Products will manage XX Ministry of Health’s organization chart, May 2018 Table 7: Alignment between the new budgetary programmes and the Ministry of Health’s reorganization (2018) Formulation of budgetary programmes (until 2018) New formulation of budgetary programmes (as formulated by Ministry of Health); post-2018 Allocation to new Directorates (from 2018 onwards) Access to health services Public health Directorate General for Public Health Delivery of health services Supply and purchasing of health care Directorate General for Health Care and Health Products Oversight Oversight and governance Directorate General for Sector Studies and Statistics Source: Authors 18 BUDGETING IN HEALTH the new national care supply programme (formerly, “delivery of health services”). The Directorate General for Sector Studies and Statistics – DGESS – will remain the lead for the third transverse programme on system governance (Table 7). When the departments in charge of the budgetary programmes in the Ministry take over the role, they will require capacity building and support in two principal areas. First of all, as required by the Minister, the newly appointed teams will have to be equipped to oversee the review of the content and outlines of the budgetary programmes (planning, prioritization, coordination both horizontally and with the levels below, definition of the performance monitoring framework). These teams will also have to be trained in the operational and financial management of a budgetary programme, from planning, spending, to financial monitoring and reporting on performance. With the appointment of programme managers in October 2017, it is expected that they become more involved both in the formulation of future programme budgets and in their implementation/execution (from 2021XXI onwards). In fact, Article 67 of LOLF states that the authorization (“engagement”) may be delegated to the programme manager who therefore “authorizes” the expenditure, with financial managers being part of each programme’s management team. The programme manager will be answerable for achieving the results. The role of the Finance and Administration Department – DAF will therefore be modified and limited to monitoring/financial reporting of the Department’s overall expenditure. The DAF is expected to be replaced by financial officers integrated in each programme unit. XXI Initially planned for 2019, the scale plan was rescheduled, in June 2018, to 2021. 19structure and content of the mInIstry of health’s budgetary Programmes Built around three major programmes, the structure of Burkina Faso’s Ministry of Health programme budget is simple. It complies with legal requirements and is aligned with the goals of the PNDS 2011- 2020. However, a more in-depth analysis reveals some weaknesses and a need to review the drafting and shaping of certain actions and activities to improve their relevance and alignment with the programme’s goals. While the programme budget has had an impact on the sector as a whole, it has specifically changed the position of specific interventions such as immunization or the fight against major epidemics, which are now part of broader budgetary programmes. 3.1 STRUCTURE OF THE MINISTRY OF HEALTH’S PROGRAMME BUDGET The Ministry of Health’s programme budget, adopted in 2017 and 2018, complies with legal requirements and follows a programme/action/activity model, in line with international recommendations (Figure 3). The “programme” level includes a public policy, a sector priority to which a goal is attached (e.g. access to quality health services), while the “action” is generally associated with a set of measures (e.g. strengthening the infrastructure) implemented to achieve the programme’s goal. In the Ministry of Health’s programme budget, an “activity” relates to more specific projects that have clearly identified costs (e.g. setting up a fund, purchasing vaccines). The number of programmes, actions and activities in the sector complies with legal requirements (maximum 7 programmes, 10 actions per programme and 40 activities). In 2018, the Ministry of Health’s first two programmes comprise six actions each, the transverse oversight programme have nine. Each action is then broken down into activities. Each action generally comprises a variable number of activities (see Appendix 2 for a detailed list of actions and activities). The access programme includes 44 activities (excluding salaries); the second, 20 activities (excluding salaries), and the last programme has 39. From 2018 onwards, the health MTEF has followed the same format as the annual budget and is structured, according to the budgetary programmes named before, besides the strategic orientations of the PNDS. This is a considerable step towards better alignment and it will make it easier to anticipate the annual budgets for each programme. 3. STRUCTURE AND CONTENT OF THE MINISTRY OF HEALTH’S BUDGETARY PROGRAMMES 20 BUDGETING IN HEALTH However, the MTEF’s usefulness is in question as the budgets have now been approved for three years (Box 2). 3.2 ANALYSIS OF THE CONTENT OF THE MINISTRY OF HEALTH’S BUDGETARY PROGRAMMES The Ministry of Health’s first two programmes meet the sector’s main and key objectives in the PNDS, namely (i) improving people’s access to quality health services (access programme); (ii) reducing morbidity and mortality through better prevention, effective care and a change of behaviour (benefits programme). Even if formulations appear to be at different levels – one at output and the other at outcome level, the content in both programmes relate to an overall system logic. By incorporating disease- specific work into broader programmes, this budget formulation paves the way for a more coordinated approach in the system. The “service delivery” programme also has an advantage from a sector point of view in facilitating the establishment of a strategic purchasing function. Different actions or activities relate to a purchasing function without links being explicitly established: action 2 relates to funds for districts, health PROGRAMME 1 ACTION 1 ACTIVITY 1 ACTIVITY 2 ACTIVITY 3 ACTIVITY 4 ACTIVITY 5 ACTION 2 ACTION 3 ACTION 4 ACTION 5 ACTION 6 Figure 3: Structure of the Ministry of Health’s budgetary programmes in Burkina Faso Source: 2016 Budget 21structure and content of the mInIstry of health’s budgetary Programmes facilities, specific dedicated funds; action 3 to the provision of care; action 5 to funds dedicated to health promotion. In light of the health financing reform, the payment systems for these different services have yet to be established/adapted. However, some imprecisions, incoherences and overlaps were detected. Although the division between the two programmes suggests that the first programme covers prevention and the second encompasses curative care following a functional approach, a more in-depth analysis of each programme’s outlines reveals that this distinction is not as clear with respect to actions. The “access” programme mainly includes actions that pertain to strengthening the health care offer (design, staff training, equipment, health products). The “services” programme, which could be thought of as related to curative services, actually includes several preventive actions (disaster health management, health promotion, community participation). In the next programme review, it is important to clarify the outlines for each programme and align their formulation with the content. An in-depth analysis for each action also suggests certain weaknesses at this level and appears to indicate a need to review their definition and formulation to improve their relevance. The programmes contain very different types of action. In the “services” programme, some refer to results (e.g. reduced endemic/epidemic disease morbidity and mortality); many others seem to refer more to activities (e.g. disaster health management). In 2001, the overall MTEF, the Medium-Term Budget Framework (MTBF), was introduced. It was structured by type of expenditure following the model used at the time in the annual budget. The first MTEF for the health sector was elaborated in 2005, following the strategic orientations of the National Health Development Plan (2001-2010). From 2011-2012, the health MTEF was formulated according to the PNDS 2011-2020’s eight strategic objectives and based on three scenarios, on the basis of Marginal Budgeting for Bottlenecks (MBB) cost estimates. The same still applies to the MTEF 2017-2020. It is considered an advocacy tool to mobilize more domestic but also external resources (external aid), by demonstrating the gap in funding between what is needed to achieve the strategic goals and the budgets allocated for the sector by the overall MTEF. Since it was decided to adopt a three-year programmes budget, the MTEF has ceased to be useful. The predictability that made the tool valuable in the annual state and sector budgets has become less important. The budget is now prepared for three years and adjusted each year according to macroeconomic forecasts and priorities. However, the health sector appears to want to retain the health MTEF in the future viewing it as a useful tool for its advocacy to mobilize resources, particularly external ones. From 2018 (MTEF 2018-2021), the structure of the health MTEF is expected to change and align with the structure of the Ministry of Health’s three budgetary programmes, on top of a PNDS divided into strategic goals and type of expenditure (based on three different scenarios). Box 2: Changes in the aggregate and sector MTEF structure in Burkina Faso 22 BUDGETING IN HEALTH In the “access” programme, actions refer more to the linchpins or inputs in a health system (personnel, infrastructure, equipment, etc.) (Table 8). XXII Some actions have been canceled between 2017 and 2018, like the action 05506. The action 05705, not present in 2017, has been reintroduced in 2018. The “activities” level appears to cover an even more diverse group of projects, which creates problems with the formulation, or means they are disconnected from the action they belong to. While some activities are well- defined and consistent with the action and the programme, others appear reductive and/ or not aligned with the programme’s goal. For Table 8: Ministry of Health’s programme budget’s programmes and actions (2018)* Programmes and actions 055 Access to health services 05501 Training of health personnel 05502 Constructing/rehabilitating health facilities 05503 Purchase and maintenance of sanitary equipment 05504 Improving the availability of quality health products 05505 Promoting systems to divide risks in the area of healthXXII 05507 Promoting traditional medicine and pharmacopoeia 056 Health service delivery 05601 Community participation 05602 Reducing morbidity and mortality associated with endemic/epidemic diseases 05603 Quality mother and child health services 05604 Disaster health management 05605 Health promotion 05606 Health product quality assurance 057 Oversight and support of Ministry of Health services 05701 Oversight, coordination and intersector collaboration of Ministry of Health actions 05702 Increase in health sector financing 05703 Management of financial and material resources 05704 Management of human resources 05705 Planning, monitoring and evaluation 05706 Building/rehabilitating and equipping administrative and educational infrastructure 05708 Health information 05709 Promoting health research 05710 Communication Source: Budget – expenditure, Ministry of Health, 2018 (CID). * Note: for the project of the finance law 2019, the proposed formulation is: 055 access to services/public health; 056 provision of health services/purchase; 057 oversight and support of services of the Ministry of Health/governance of health system 23structure and content of the mInIstry of health’s budgetary Programmes example, with respect to promoting health, the main action, in 2017, is to “ensure the central and other authorities are working”, which does not appear to be directly focused on achieving the expected result (“improve hygiene, sanitation and behaviours conducive to good health”). Another example relates to the oversight programme; the “increased funding” action is linked to the programme budget formulation activity, which is certainly insufficient to increase funding, even though it can contribute towards advocacy for more resources for the sector. 3.3 IMPLICATIONS OF THE REFORM FOR SPECIFIC HEALTH PROJECTS (IMMUNIZATION, HIV/AIDS, MALARIA, TUBERCULOSIS) The transition to the programme budget affected the budget item to which expenditure on disease-specific projects was charged, an aspect little known to national or international partners (e.g. Global Fund, GAVI) in these sectors. Their position in the budget has changed and it is important to map and monitor this development. At this stage, interventions seem to be in the correct place (“activities”) and corresponding to a rationale that is consistent with the PNDS. While a more in-depth understanding of the consequences of this transition on funding for diseases is still a little premature, at this stage it does not appear to have affected the level of funding for each disease/project.XXIII With regard to immunization, before the reform, budgetary provisions for immunization XXIII Rising for immunization, for example: from 2.2 billion CFA francs in 2017 to 3.2 billion CFA francs in 2018. came primarily under two main headings: purchasing vaccines and consumables and support for national immunization days (NID). Since the transition to a programme budget, this expenditure is now divided between the two budgetary programmes (access and services). Both operations can be found under “activities”.XXIV The purchase of vaccines is now charged as an activity in the “Access to services” programme, under the “Improving the availability of quality health products” action. As for the contribution to the financing of NIDs, this activity is included in the “Health Services Delivery” programme, under the “Quality health services for mother and child health” action (Table 9). The situation is different for each of the three major epidemics (HIV/AIDS, tuberculosis and malaria). While some provisionsXXV are planned by the Ministry of Health, HIV/AIDS-related projects are mainly funded by the National multisector programme to combat HIV/ AIDS and sexually-transmitted infections, a programme of the National council to combat HIV/AIDS and STDs placed under the auspices of the Presidency. Before the 2017 budget reform, spending on national resources was divided in the Presidency section into operating expenditure, a grant for the AIDS Solidarity Fund, and an entry under investment for the “project to XXIV Although the budget item to which it was charged is different, the nature of the expenditure does not change (e.g. transfers for national campaigns). XXV “Ensure the functioning of the HIV/AIDS/STD sector” provision/activity, “Health service delivery” programme and “Ensure the effective functioning of the Ministerial Committee to Combat AIDS/STD (CMLS-STD)” provision/ activity, “piloting and support” programme. 24 BUDGETING IN HEALTH support the implementation of the Strategic Framework for the fight against AIDS”. From 2017 onwards, the provisions were grouped under a “Fight against HIV, AIDS and STDs” programme divided into three actions: 1) Preventing the transmission of HIV/AIDS and STDs; 2) Care, treatment, support and protection of those who are affected; and 3) Governance, funding of the response and strategic information management” (Table 9). The Ministry of Health is responsible for a number of activities that respond to the aforementioned three actions, either on its own (e.g. promoting sexual and reproductive health) or alongside other ministries (e.g. promoting safer behaviour). Although the Ministry of Health is responsible for the implementation of some activities, the budgetary allocation remains with the Presidency. The fight against tuberculosis is mainly financed external by partners (partly off- budget). With respect to state budget provisions through the Ministry of Health, the shift to a programme budget format required including funding dedicated to the prevention and fight against this disease in the “benefits” programme. The provisions were previously essentially a contribution to the operation of the National and regional tuberculosis control centre and to the National reference laboratory for tuberculosis, as well as a non-itemized provision to run the National tuberculosis control programme (under the Department of Health operating subsidy). Since the transition to the programme budget, this same earmarked funding has been charged to the “benefits” programme under the “reducing endemic/epidemic morbidity and mortality” action, and the “support for the national tuberculosis control centre” activity. Other unrestricted funding also covers actions/activities related to the fight against tuberculosis including: the staff, the running of diagnostic and treatment centres, the monitoring and dispensing of treatment devolved to the health and welfare centres, as well as the payment of allowances to CBHWs who perform screening activities/provide support with treatment compliance. With regard to malaria, domestic funding is historically associated with two main types of activities: 1) a provision to run the National malaria research and training centre, which is now part of the “Steering and support for Table 9: Allocation of pre-reform and post-reform immunization expenditure Pre-reform (before 2017) Post-reform (2017 & 2018) Heading Programme Action Activity Heading 3. Operating expenses Chap. 65137. Department of prevention through immunization 621 62. Medical immunization products 621 69. Other specific supplies 055. Access to health services 05504. Improved availability of quality health products 0550401. Purchase vaccines and consumables Heading 4. Current transfers Chap. 61141. National Immunization Days 056. Health service delivery 05603. Quality health services for mother and child health 0560303. Organize national immunization days Source: Budgets 2016, 2017, 2018 (CID)18 25structure and content of the mInIstry of health’s budgetary Programmes services” programme under the “Promotion of health research” action; 2) funding for preventive or curative activities related to the free programme (Table 11). The free health care programme for children under 5 years of age and for pregnant (preventive and curative) and postpartum (curative) women, now included in the “access” programme, covers much of the funding of malaria-related activities owing to malaria’s importance both in preventive and curative activities for children and pregnant women. From 2017, a specific “Ensuring the implementation of the free health care strategy” activity was included in the “Promotion of mechanisms for sharing health risks” action in the “Access to health services” programme. A second activity in the same programme that refers to the “Improving the availability of quality health products” action, was however maintained to cover the purchase of malaria drugs, among others. These two budget “items” cover the authorities’ contribution to subsidizing “free” treatment in the fight against malaria. Table 10: Actions and activities posted under the Presidency’s “Fight against HIV, AIDS and STDs” budget plan Actions Activities Action 1: Preventing the transmission of HIV/AIDS and STDs Promoting safer behaviour through Information Education Communication/ Behaviour Change Communication and Sexual and Reproductive Health; promoting male and female condom use; promoting sexual and reproductive health and screening advice; eliminating mother-to-child transmission of HIV (+ projects financed externally) Action 2: Care, treatment, support and protection of infected and affected individuals Strengthen biological, medical-technical and clinical services; strengthen the drug supply system, including ARVs, reagents, consumables and equipment; increase the involvement of associations and communities in the continuum of care for people infected and affected by HIV; improve the financial support for PLHIV, people who are affected and specific groups in all sectors Action 3: Governance, financing the response and strategic information management Ensure the leadership is coordinated and maintained; strengthen the organizational and institutional capacities of facilities; ensure internal and external resources are mobilized; conduct epidemiological, sector behaviour and impact studies; improve the organization of the national monitoring and evaluation system; document and disseminate best practice in the fight against HIV and STDs Source: Budget – expenditure, Faso Presidency, 2018 (CID). Table 11: Budget allocation of malaria prevention and management expenditure in the programme budget (post-reform) Programmes Actions Activity Steering Promoting Health Research Ensuring the functioning of the National malaria research and training centre Access Promoting risk-sharing mechanisms Ensuring the implementation of the free health care strategy Improving the availability of health products Purchasing malaria drugs Source: 2017 & 2018 Budget 26 BUDGETING IN HEALTH The sector’s transition to the programme budget in 2017 and 2018 brought a certain degree of flexibility in public health expenditure. The adjustments and reallocations between 2017 and 2018, and between and within budgetary programmes in the same year, are all signs of more flexible budget programming. Expenditure practices are also becoming more flexible and are shifting towards spending that is more responsive to the sector’s changing needs. If Burkina Faso adjusts the programme budget performance monitoring framework, it will then have a very useful tool that provides information on programmatic and financial performance of the sector and which would inform future allocation decisions between and within programmes. 4.1 MOVING TOWARDS AN END TO ANNUAL DEFERRED BUDGETARY PROGRAMMES? The formulation of the budgetary programmes evolved between 2017 and 2018; adjustments in actions and activities made it possible to improve the programmes’ alignment with the items beneath them. For example, in 2018, the “functioning of central and regional directorates” activity was charged to the “oversight and support of services” programme, whereas in 2017 it had been included in the “health promotion” action of the “delivery of services” programme. The “functioning of health districts and university/ regional hospitals” activity was transferred from the “health promotion” to the “reducing endemic/epidemic morbidity and mortality” action in the “Services” programme. New activities were included, moving away from a budgeting approach that carries forward the same level of allocation for the same activities from one year to the next. A key point was added under “Reducing endemic/ epidemic morbidity and mortality”, which now includes support for districts, regional health facilities and tertiary entities (university/ regional hospitals). Also, the “Community- based health worker management” activity was added under “community participation” in 2018, whereas no activity had been recorded in 2017. Two activities were added to the management programme (“Payments to the health research support fund; Ensuring that the National institute of public health (INSP) is operational)”, while 2017 only provided for more targeted support for two local research facilities. In addition to the formulation, the allocations to the various programmes were reviewed each year. In 2017, the largest allocations were for the “access” programme (52% of the total Ministry of Health budget), while the “benefits” programme has the largest share of the budget in 2018 (47%). The “oversight” programme is relatively unchanged at 12% and 14% for 2017 and 2018 respectively (Figure 4). While the Ministry of Health’s global budget changed little from 2017 to 2018 (+2%), there were major variations between and within programmes and actions. The differences are 4. FIRST EFFECTS OF THE REFORM (2017-2018): PROGRESS AND CHALLENGES 27fIrst effects of the reform (2017-2018): Progress and challenges mainly due to a substantial transfer of staff costs from the “access” programme to the “benefits” programme (-76%/+83%), but a different allocation for certain activities can also be observed between 2017 and 2018. For instance, variations of more than 70% were seen in health promotion, service provision for mother and child and health product quality assurance (see details in Appendix 3). 4.2 TOWARDS MORE FLEXIBILITY IN SPENDING? A key innovation lies in the set up of more flexibility in expenditure and the «relaxing» of some ex ante controls to authorize expenditures. The commitment is now done on the basis of programme with a justification at the level of «section» (and not at the paragraph anymore). However, it is worth noting that in a certain way, the input-based logic is still present in the authorization process of expenditure, through the request of justification by section («rubrique»). Flexibility in expenditure is reflected in practice through varying levels of execution between and within programmes. Table 12 shows these varying levels of implementation between the two main programmes (115% implementation for the “access” programme and 66% for the services programme in 2017), while maintaining a relatively satisfactory overall level of implementation (93%). Apart 51,8% 35,8% 12,4% Budget 2017 37,6% 47,5% 14,9% Budget 2018 055 Access to health services 056 Health service delivery 057 Oversight and support Figure 4: Distribution of budget appropriations by programme in 2017 and 2018, Ministry of Health Source : Ministère de la Santé, 2017 et 2018 28 BUDGETING IN HEALTH from personnel, fungibility provides the flexibility for expenditure items within the same programme to vary up or down with no pre-set limit. The level of implementation of the actions within the programmes themselves varies significantly from 33% to 175%. While variations in the implementation levels of activities are probably due to the lack of stabilization in the activities, they are likely to be associated financial management that is more flexible than before and that is more responsive to the sector’s changing needs. Health personnel costs are charged to each of the Ministry of Health’s budgetary programmes.XXVI They therefore avoid the common pitfall of being registered and managed outside the programmes within a specific staff line or lines. The Ministry of Health’s budget therefore includes three “blocks” for remuneration (the “balance”), which are connected to the first action in each programme (with no specific relation to the content of the action) and could have the advantage of including a major cost factor (58% of expenditure within the “benefits” XXVI Personnel expenditure at tertiary level (university/regional hospital) is accounted for in transfers to these bodies and is therefore not included in the remuneration expenditure programme in 2018 for example) as part of a true model of programme efficiency. However, the implementation of staff costs differs significantly from the 2017 allocations, implying an unreliable estimate of needs. In the “access” programme, implementation is much higher than stated in the initial budget (190% of the revised provisions). For the “services” programme, only 25% were executed. In 2018, there will be a mass transfer of salaries to the “benefits” programme (twice the allocations of 2017), which will now cover 70% of salaries, while allocations in the “access” programme will be cut to one third. Since salaries remain the Ministry of the Economy, Finance and Development’s responsibility, in practice, dividing staff costs across the Ministry of Health’s three programmes therefore appears to be a rather artificial exercise. The entries are not in fact linked to the action they have been logged under. In the first programme, salaries appear under “training health staff” and in the second programme, under “community participation”. The expenditure relates to a retroactive entry in the monitoring of the expenditure because, even if it is charged to the health budget, there is limited room for manoeuvre for health to adjust the Table 12: Implementation of the health budgetary programmes (2017) Initial provision (thousands CFA francs) Revised provision (thousands CFA francs) Settlement (thousands CFA francs) Implementation (%) Access to health services 121,287,749 101,457,294 117,515,245 115.8% Provision of health services 71,585,283 70,051,757 46,313,277 66.1% Steering and support 23,193,257 24,210,695 19,069,684 78.8% Total 216,066,289 195,719,746 182,898,206 93.4% Source: CID, 2017 29fIrst effects of the reform (2017-2018): Progress and challenges payroll to meet each programme’s goals (see section 1.2). Until the Department has the capacity to incorporate staff management and remuneration more effectively into the programmes, it will be limited in its ability to move towards more strategic purchasing of services and hence more flexible and efficient spending. Table 13: Extract from the Ministry of Health programme budget’s Performance Monitoring (2018-2020) Strategic objectives Indicators Reference Targets Responsible directorate Unit Year Value 2018 2019 2020 Programme 056 Health service delivery Reduce morbidity and mortality for better prevention, effective treatment and a change in behaviour Maternal mortality rate RATIO 2016 341 243 243 243 DGESS Mortality rate for children under five RATIO 2016 ND 62,75 62,75 62,75 DGESS Action 05601 Community participation Promote community-based action in the area of health Number of NGOs who have a performance contract with the Ministry of Health NO. 2016 252 252 252 252 DGS Number of villages covered by the OBC-E NO. 2016 8000 8000 8000 8000 DGS Action 05602 Reducing morbidity and mortality related to endemic/epidemic diseases Promote community-based action in health1 New contacts per inhabitant and year in the primary health care facilities (CM and CSPS) NO. 2016 1,02 1,3 1,4 1,5 DGESS Bed occupancy rate in the hospitals % 2016 50,5 60 65 70 DGS Action 05603 Quality service offer for mother and child Improve mother and child health Rate of assisted deliveries % 2016 80,9 >=87 >=90 >=90 DGESS Rate of caesarean sections among assisted births % 2016 >=3.5 >=3.8 >=3.9 >=4 DGESS Immunisation rate of pentavalent vaccine among children % 2016 103 100 100 100 DGESS Action 05604 Disaster health management Improve disaster health management Coverage rate for disaster victims % 2016 NA 80 80 80 DGS Proportion of hospitals with a response plan <plan blanc> % 2016 100 100 100 100 DGS 1 The repetition of actions between 05602 and 05601 is provided in the original document. DGESS: Directorate general of sector studies and statistics DGS: Directorate general of health Source: Budget 201819 30 BUDGETING IN HEALTH 4.3 TOWARDS FINANCIAL ACCOUNTABILITY THAT IS OF BENEFIT TO THE SECTOR? The programme budget is combined with the implementation of a performance monitoring framework (PMF)21 that makes it possible to link changes in the sector’s performance to the resources that have been allocated, creating monitoring that had not previously existedXXVII. The PMF is defined according to the programme (and not by input) and aims to provide information on achieving the goal that has been set for each of the two programmes, namely “improving access to quality health services” and “reducing morbidity and mortality through improved prevention, effective treatment and changes in behaviour” (see section 3.2). The performance framework has the advantage of being at programme and action level. The programme manager is therefore expected to report to action level and not to a lower level (activities), therefore giving them some autonomy in the implementation of activities. They will not be judged on whether XXVII Performance monitoring under the PNDS does not link the achievement of the goals directly to the expenditure to achieve these same goals. or not an activity is complete, but on whether a particular result has been achieved for the sector, depending on the resources that have been allocated (Table 13). While the volume of performance data to be reported appears to be relatively moderate at this stage in comparison to international standards,XXVIII the performance framework would appear to require adjustment if it is to measure the achievement of the expected results. The indicators, which are currently aligned with the PNDS, do not follow a clear “logical framework” between results and inputs. If Burkina Faso adjusts the framework, it will then have a very useful tool to provide information on sector programmatic/ operational and financial performance and inform future decisions on allocations between and within programmes. If annual performance monitoring is used to influence future decisions on allocations in the sector, the programme budget and its performance framework will be able to make a significant contribution to the sector. XXVIII One sole outcome indicator is provided, and a maximum of three outcome indicators per action are suggested. 31summary of Progress, challenges and recommendatIons SUMMARY OF PROGRESS, CHALLENGES AND RECOMMENDATIONS Summary of progress and challenges in the implementation of the health programme budget in Burkina Faso Progress Challenges Budget planning Aligning budget formulation with PNDS (2011-2020) priorities Need to update the outlines and content of budgetary programmes in light of new policy directions for the sector Year-to-year adjustments between and within programmes Usefulness of the MTEF given that the budget is defined for three years Harmonizing departmental organization and budgetary programmes to facilitate implementation and accountability Delay in appointing managers following the reorganization of the Ministry of Health, which could not affect the budget planning before 2019 “Responsibility chain” to be redefined following the ministry reorganization Implementing expenditure Financial management tools adjusted to programme budgeting Non effective transferring of expenditure authorizing to programme managers Effective implementation of the principle of decentralized authorizing at the benefit of health Minister Artificially including staff remuneration with programme formulation Effective implementation of the fungibility principle at programme level Fungibility authorised/justified on the basis of inputs Performance monitoring and accountability Annual performance monitoring at programme and action level Relevance and consistency of performance framework to be improved Technical capacity and ownership Understanding, ownership and leadership in the design of programme budget by ministry of Health Lack of ownership by newly appointed programme managers Strong DAF teams formed “Operational” teams not complete and not trained to manage effectively budgetary programmes 32 BUDGETING IN HEALTH RECOMMENDATIONS The following roadmap was defined and reviewed and refined by participants of the MOH/WHO seminar on programme budget in health, organized in Ouagadougou on 11-12 July 2018 Formulation of budgetary programmes in health: Reformulate the name, the content, and the outline of the budgetary programmes according to new orientations of the sector; Use the results of the annual reports on performance to inform the budgetary allocations of the following year; Ensure coherence in the performance monitoring framework with the new budgetary programmes; Clarify the purpose of the sectoral MTEF (information and advocay), the three- yearly budget in front of the primary tool for budgetary programming. Implementation and monitoring of the budgetary reform in health: Take part and use the results reform review to integrate the lessons for a rapid implementation of the reform in 2020- 2021; Formulate and make more operational the communication and coordination mechanisms between and within the budgetary programmes teams, at a financial and operational level; Prepare the effective transition of the financial management of programmes, including the integration of financially in charge people within the programmes; coordinate the implementation of the budget reform with the reform of health financing, specifically related to the universal health insurance scheme and the other measures concurring to a more strategic purchasing of health services; ensure coherence between the institutionalizing of budget reform with the implementation of decentralization(in particular pending transfers of skills to the regions); make progress with the Ministry of Finance and the Civil Service on allocating the remuneration of health personnel at the programme level Implementation of the teams and capacity building: Finalize the assignments, organization and the working of the different entities and the new created directorates according to the organization chart of 2018 of the Ministry of Health; Strengthen programme managers’ capacities to prepare and manage the budgetary programmes by giving them a specific training; Make the teams of the programme managers operationnal, by including trained financial managers in each programme. 33summary of Progress, challenges and recommendatIons BIBLIOGRAPHY 1. Barroy H, Dale E, Sparkes S, Kutzin J. Budget matters for health: key formulation and classification issues, Policy brief N°4, World Health Organization, 2018 (http://apps.who. int/iris/bitstream/handle/10665/273000/WHO-HIS-HGF-PolicyBrief-18.1-eng.pdf?ua=1) 2. World Health Organisation. Budgeting in health, Genève : Organisation mondiale de la Santé (http://www.who.int/health_financing/topics/budgeting-in-health/en/) 3. Union économique et monétaire ouest-africaine. Guide didactique de la Directive n°06/2009/ CM/UEMOA portant lois de finances au sein de l’UEMOA. Dakar : UEMOA, 2009 (http:// www.droit-afrique.com/upload/doc/uemoa/UEMOA-Directive-2009-06-lois-de-finances. pdf, consulté le 15 mai 2018) 4. Union économique et monétaire ouest-africaine. Rapport de mise en oeuvre du cadre harmonisé des finances publiques, 2e réunion de l’Observatoire des Finances Publiques. UEMOA, Lomé, 7-11 novembre 2016. 5. Secrétariat général du gouvernement et du Conseil des ministres. www.legiburkina.bf 6. Lawson A., Chiche M., Ouedraogo I. Évaluation de la réforme de la gestion des finances publiques au Burkina Faso 2001–2010, Danida, Rapport d’étude de cas pays – version finale. Danish International Development Assistance (Danida), Swedish International Development Cooperation Agency (Sida). Stockholm, 2012 (https://www.oecd.org/fr/pays/burkinafaso/ burkina_francais.pdf, consulté le 15 mai 2018) 7. Ministère de l’Économie et des Finances. Politique sectorielle 2011-2020 de l’économie et des finances – POSEF 2001-2010. Ouagadougou, 2011. (http://www.sips.gov.bf/img_tmp_ fichiers/MEF-PS-1.pdf, consulté le 15 mai 2018) 8. Ministère de la Santé. Stratégie nationale de financement de la santé pour la couverture santé universelle, 2017-2030. Ouagadougou. Octobre 2017 9. Ministère de la santé. Comptes nationaux de la santé, 2015 10. Kelley A.et al. Une vue d’hélicoptère : cartographie des régimes de financement de la santé dans 12 pays d’Afrique Francophone. Communauté de Pratique Accès financier aux Services de Santé et Communauté de Pratique Financement Basé sur la Performance, 2014 (http://docplayer.fr/amp/76977257-Une-vue-d-helicoptere-cartographie-des-regimes- definancement-de-la-sante-dans-12-pays-d-afrique-francophone.html, consulté le 15 mai 2018) 34 BUDGETING IN HEALTH 11. ASMADE. Inventaire des mutuelles sociales dans la perspective de l’assurance maladie universelle au Burkina Faso. Ouagadougou, 2011 (http://ongasmade.org/new/images/PDF/ ouvrages/INVENTAIREDESMUTUELLESSOCIALES2011VF.pdf, consulté le 15 mai 2018) 12. Étude sur le système mixte de modalités d’achat et de paiement des services de santé : Cas du Burkina Faso. Genève, Organisation mondiale de la santé, 2017. 13. Code général des collectivités territoriales 2004 14. Décret 2009-109/PRES/PM/MFPRE/MATD/MEF du 3 mars 2009 portant transfert des compétences et ressources de l’État aux communes dans le domaine de la santé 15. Décret 2014/920/PM/PATD/MDS/MEF/MFPTSS du 10 octobre 2014 portant transfert des compétences et ressources de l’État aux régions dans le domaine de la santé 16. Circulaire budgétaire n°97-054/PRES du 26 mai 1997 pour la préparation de la loi de finances-gestion 1998 17. Décret N° 2016-600 sur la nomenclature budgétaire 18. Écran d’engagement du Circuit informatisé de la dépense (CID) à la date du 14 février 2018 19. Ministère de la Santé. Cadre de performance des programmes budgétaires du Ministère de la santé, 2018-2020. 35bIblIograPhy LIST OF OFFICIAL DOCUMENTS REVIEWED Public financial management and programme budget documents DANIDA, Evaluation of Public Financial Management Reform in Burkina Faso 2001-2010, Country case study report – Final version, June 2012 Ministry of the Economy and Finance, Detailed report of the medium-term fiscal framework 2016-2018, April 2015 Ministry of the Economy and Finance, Economic and financial sector policy 2011-2020, April 2011 Ministry of the Economy and Finance, Guidance document for the implementation of the programme budget in Burkina Faso, June 2010 Ministry of the Economy and Finance, Methodology guide for drafting the government’s programme budget, Ministry of the Economy, Finance and Development, Forecast of overall expenditure by type 2018-2020 Ministry of the Economy, Finance and Development, Multiyear budget and economic planning document 2018-2020, April 2017 Ministry of the Economy, Finance and Development, Proposed staff costs 2017-2019, Baseline scenario, Ministry of the Economy, Finance and Development, Programme budget implementation guide, Public expenditure component, April 2017 Ministry of Health, Medium-Term Expenditure Framework 2016-2018, 12th edition, December 2015 Ministry of Health, Medium-Term Expenditure Framework 2017-2019, 13th edition, December 2016 Ministry of Health, Medium-Term Expenditure Framework 2018-2020, 14th edition, December 2017 Ministry of Health, Ministry of Health programme budget 2013-2015, September 2012 36 BUDGETING IN HEALTH Ministry of Health, Ministry of Health programme budget 2015-2017, Final Version, September 2014 Ministry of Health, Ministry of Health programme budget 2016-2018, draft, June 2015 Ministry of Health, Ministry of Health programme budget 2017-2019, October 2016 Ministry of Health, Ministry of Health programme budget 2018-2020 Ministry of Health, Settlement bond No. 2017-2140-6 of 23 October 2017 Public financial management and statistics support programme, Mid-term evaluation of Economic and financial sector policy 2011-2020, 2015 West African Economic and Monetary Union, Press statement of the ordinary session of the Council of Ministers of the Union, Dakar, 31 March 2017 Health-specific documents National assembly, Summary report of the parliamentary inquiry into the health system in Burkina Faso 2006-2016, July 2017 Ministry of Health, Classification of National Health Development Plan 2011-2020 activities (Phase II), May 2017 Ministry of Health, Draft national health sector policy, August 2017 Ministry of Health, Guide for drawing up annual action plans for central and technical directorates, December 2017 Ministry of Health, Health sector policy support project (PAPS/UE-Lot2), Draft study report on the mission, role and functioning of the health district in the light of current reforms, June 2017 Ministry of Health, Joint assessment of the National Health Development Plan in Burkina Faso 2011-2020, Final assessment report, September 2016 Ministry of Public Service, Labour and Social Welfare, Classification and tariffs of professional health procedures in public health facilities and hospital establishments in Burkina Faso, draft report, July 2017 Ministry of Health, Mid-term evaluation report of the PNDS 2011-2020 Burkina Faso, Ministry of Health, Mid-2017 Performance sector report, National Plan for Economic and Social Development, Health planning sector, August 2017 37bIblIograPhy Ministry of Health, Monitoring and Evaluation Plan of the Malaria Strategic Plan 2016-2020, January 2017 Ministry of Health, National Health Development Plan 2011-2020, 2011 Ministry of Health, National Health Development Plan PNDS 2011-2020, Phase 2016-2020, December 2016 Ministry of Health, National health financing strategy for universal health coverage 2017-2030, October 2017 Ministry of Health, National plan for managing insecticide resistance by malaria vectors 2016- 2020, December 2018 Ministry of Health, National Strategic Plan for Malaria Control 2016-2020, October 2016 Ministry of Health, National strategy for the implementation of free health care for women and children under five, December 2017 Ministry of Health, Planning guidelines 2018, January 2018 Ministry of Health, PNDS Monitoring and Evaluation Plan 2011-2020, January 2012 Ministry of Health, Sector performance report 2016, Health planning sector, March 2017 Ministry of Health, Strategic Plan for Tuberculosis Control 2018-2022, June 2017 General documents and working instruments Burkina Faso, National Plan for Economic and Social Development 2016-2020, July 2016 Computerized expenditure system, Budget implementation, State funding, Fiscal year 2017, on 30 February 2018 Computerized expenditure system, Budget implementation, State funding, Fiscal year 2018, on 30 February 2018 Computerized expenditure system (CID) draft settlement screen Computerized expenditure flow, Table of cost of activities by action and programme (thousands of FCFA) Integrated financial management system (CID) validation screen on 14 February 2018 38 BUDGETING IN HEALTH Ministry of the Economy, Finance and Development, Basic structure for drafting programme budget documents Ministry of Health, Criteria and key aspects for allocating state budget funds, management 2018 Ministry of Health, Key aspects and criteria for allocating the 2014 state budget Ministry of Health, Report on the workshop to review the criteria and keys for allocating state budget funds, May 2014 Ministry of Health, Total Ministry of Health expenditure by action, 31 December 2017 Ministry of Health, Total Ministry of Health expenditure by action, 31 January 2018 Ministry of Health, Total Ministry of Health expenditure by programme and type, 31 December 2017 Ministry of Health, Total Ministry of Health expenditure by programme and type, 31 January 2018 Ministry of Health, Transition Matrix Programme budget, National health development policy, July 2017 Ministry of Regional Administration and Decentralization, Validation form No. 2018-0913-9 of 05 February 2018 WAEMU, Training guide for Directive No. 06/2009/CM/WAEMU on the Finance Act in WAEMU WAEMU, Report on the implementation of the harmonized framework for public finances, second meeting of the Public finance monitoring unit, Lomé, 7-11 November 2016 Regulatory and institutional texts Act No. 040-2016/AN of 15 December 2016 on the Finance Act for the implementation of the state budget, 2017 financial year Act No. 052-2017/AN of 27 November 2017 on the Finance Act for the implementation of the state budget, 2018 financial year Act No. 008-2013/AN of 23 April 2013 on the general code of transparency in public financial management in Burkina Faso Act No. 039-2016/AN of 02 December 2016 on the general regulation of public procurement 39bIblIograPhy Act No. 073-2015/CNT of 06 November 2015 on the Institutional act on finance laws (LOLF) in Burkina Faso Circular No. 2016-0001/PRES of 22 June 2016 on the drafting of the government budget, financial year 2017 Circular No. 2017-0386/MINEFID/CAB on the role of the parties involved in the implementation of the programme budget in the transitional phase of the enforcement of the LOLF, February 2017 Decree No. appointing budget plan officers representing the Ministry of Health, Council of Ministers of 18 October 2017 Decree No. 2016- 601/PRES/PM/MINEFID of 08 July 2016 on the conceptual framework of state accounting Decree No. 2016-311/PRE/PM/MS/MATDSI/MINEFID of 29 April 2016 on free health care for women and children under five living in Burkina Faso Decree No. 2016-598/PRES/PM/MIINEFID of 08 July 2016 on general regulations on public accounting Decree No. 2017-0004/PRES/PM/MlNEFID of 12 January 2017 on the establishment, powers, organization and functioning of the National Plan for Economic and Social Development monitoring and evaluation system Decree No. 2016-753/PRES/PM/MS of 16 August 2016 on the organization of the Ministry of Health Decree No. 2018-0093/PRE/PM/MS of 15 February 2018 on the organization of the Ministry of Health Decree No. 2017-0049/PRES/PM/MINEFID of 1 February 2017 on procedures for awarding, executing and regulating public procurement and the delegation of public services Decree No. 2014-920/PRES/PM/MATD/MS/MEF/MFPTSS of 10 October 2014 on the transfer of powers and resources in health and hygiene from the State to the regions Decree No. 2009-108/PRES/PM/MATD/MS/MEF/MFPRE of 3 March 2009 on the transfer of powers and resources in the health sector from the State to municipalities Directive No. 06/2009/CM/WAEMU of 26 June 2009 on finance laws in WAEMU Directive No. 01/2009/CM/WAEMU of 27 March 2009 on the code of transparency in the management of public finances in WAEMU 40 BUDGETING IN HEALTH Directive No. 07/2009/CM/WAEMU of 26 June 2009 on the general regulation on public accounting in WAEMU Directive No. 08/2009/CM/WAEMU of 26 June 2009 on the government budget classification in WAEMU Directive No. 09/2009/CM/WAEMU of 26 June 2009 on the government chart of accounts (PCE) in WAEMU Interministerial order No. 2017-018/MINEFID/MATDS/MS of 12 January 2017 on the allocation of two billion two hundred and eighty-four million one hundred and forty-seven thousand three hundred and eighty-two (2,284,147,382) CFA francs representing the financial resources transferred to the municipalities for the powers transferred in the area of health with respect to recurring charges pertaining to the State budget, financial year 2017 Interministerial order No. 2017-020/MINEFID/MATDSI/MS of 24 January 2017 on the allocation of two billion nine hundred and ninety-nine million nine hundred and eighty-eight thousand and forty-five (2 999 988 045) CFA francs representing the financial resources transferred to the municipalities to support the powers transferred in the area of health with respect to investments pertaining to the State budget, financial year 2017 Joint order No. 2016-608/MS/MINEFID of 7 November 2016 on determining eligible expenditure in the context of free health care for women and children under the age of five in Burkina Faso Letter No. 2017-0386/MINEFID/CAB of 14 February 2017: role of the parties involved in the implementation of the programme budget during the transitional phase of the enforcement of the LOLF Order No. 2017-1244/MS/SG/DAF of 08 September 2017 amending the budget appropriations of programme 056 of the Ministry of Health, financial year 2017 Order No. 10/2009/CM/WAEMU of 26 June 2009 on the government financial operations table in WAEMU 41aPPendIxes APPENDIX 1: BUDGET-PLANNING PROCESS SINCE THE ADOPTION OF THE PROGRAMME BUDGET The process and various parties involved in the ministerial budget planning are as follows: Presidential circular launching the budget-planning process setting out the assumptions and budget framework, as well as the general and sector-specific priorities and the strategic budgetary choices adopted by the authorities (outline of the BP attached). Send the ministries’ and institutions’ reference allocations to the departments, by type of expenditure, to implement the programmes they are responsible for, as specified in the Multiyear budget and economic planning document drawn up by the Directorate general for the budget of the Ministry of Finance (general MTEF). Minister of Health sets up the Budget planning committee and subcommittees, according to the type of expenditure. This committee sends the various entities in the Ministry (Directorates, regional/ district health directorates, university/ regional hospitals, establishments, etc.): (1) the provisions granted to each of them according to the intrasector distribution and total amounts allocated to operating and/or transfer appropriations; (2) a request framework to ascertain the financial needs/cost of “activities” for each, according to the economic classification of the expenditure. The committee selects and consolidates the various requests sent by the entities and incorporates them in the actions and programmes; specific work on staff costs and investment according to the information requested by the Directorate general for the budget; validation by the ministerial authorities. DAF planning department includes all the information and tables needed to prepare the Ministry of Health draft programme budget in the CID (programming module), including the programmes’ performance framework; finalize the sector “Programme budget” document. Discussion of the ministerial budget proposal (summary table and “Programme budget” document) at a Budget Committee with the Ministry of the Economy, Finance and Development before inclusion in the draft budget/ government Finance Law, which will be presented and validated in the Council of Ministers before being submitted to the National Assembly (Draft Finance bill and all the documents prescribed by the LOLF including the ministerial “Programme budget” documents). APPENDIXES 42 BUDGETING IN HEALTH APPENDIX 2: LIST OF THE MINISTRY OF HEALTH’S PROGRAMME BUDGET’S ACTIONS AND ACTIVITIES Programmes, actions and activities 055 Access to health services 05501 Training of health personnel Ensure support for students at the end of their studies, interns, doctors undergoing specialized training; ensure the continuing training of staff; ensure the National School of Public Health continues to provide training + 2018 Ensure a single examination is organized 05502 Construction/rehabilitation of health infrastructure and 05503 Purchase and maintenance of health equipment Various investment projects 05504 Improving the availability of quality health products Purchase vaccines and consumables; purchase drugs; purchase therapeutic foods/micronutrients (consolidation of social safety net); purchase health products (reagents, malaria drugs, medical and blood consumables – social safety net); support dialysis unit and running of the blood transfusion centre 05505 Promoting health risk-sharing schemes Ensure the implementation of the free health care strategy 05507 Promoting traditional medicine and pharmacopoeia Organize the African Traditional Medicine Days 056 Health service delivery 05601 Community participation 2017: (no activity) 2018: Care for community-based health workers (CBHW) 05602 Reducing morbidity and mortality associated with endemic/epidemic diseases 2017: Specific funds (fight against neglected tropical diseases, response to epidemics, national disease control funds, funds to support the vulnerable persons programme, etc.); Specialist centres (tuberculosis, blindness) 2018: Specific funds (fight against neglected tropical diseases, response to epidemics, national disease control funds, support funds for the vulnerable persons programme, etc.); districts (monitor the running of the health districts); university, regional and district hospitals (monitor the running* of university and regional hospitals); specialist centres (tuberculosis, blindness); HIV/AIDS sectoral programme 05603 Quality mother and child health services Purchase contraceptive products; Organize National Immunization Days; + 2017: HIV/AIDS sector programme  05604 Disaster health management Supply the national fund for the fight against epidemics 05605 Health promotion 2017: Monitor the running of central administrations, regional health directorates (monitor the running of decentralized bodies); Districts (monitor the running of decentralized bodies); university, regional and district hospitals (monitor the running* of public health establishments); management of CHBW; health promotion in the towns (ensure commitments to the global fund to tackle certain diseases) 2018: Health promotion in towns (support health promotion activities in towns); 43aPPendIxes Programmes, actions et activités 057 Department of health services’ oversight and support 05701 Ministry of Health oversight, coordination and intersector collaboration Contribution to international organizations 2018: Functioning of central administrations; regional health directorates (functioning of regional health directorates); Contribution to international organizations 05702 Increase in health sector financing Drafting the Ministry of Health programme budget 05703 Management of financial and material resources Cover the expenses of medical evacuation (transport and hospitalization expenses); cover the project’s expenses, water/electricity, telephone, etc. 05704 Management of human resources Support the functioning of the professional bodies; + 2017, Ensure the organization of single screening 05705 Planning, monitoring and evaluation 2017: Action not selected 2018: Develop planning guidelines, hold National Plan for Economic and Social Development sector dialogue framework sessions, update health card, 05706 Building/rehabilitating and equipping administrative and educational infrastructure Various activities: office furniture equipment, computer equipment, building district management team offices, etc. 05708 Health information Support the running of the drug information and documentation centre + 2018: Develop national health accounts 05709 Health Research Promotion Support operations at the National malaria research and training centre, the Muraz centre, the Nouna health research centre + 2018: Supply the fund to support health research; Ensure the operation of the National institute of public health (INSP) 05710 Communication Support Ministry of Health communication APPENDIX 2: continued 44 BUDGETING IN HEALTH APPENDIX 3: VARIATION IN ALLOCATIONS BY PROGRAMME AND ACTION BETWEEN 2017 AND 2018 By programme and action 2017 2018 74.566.207 055 Access to health services Revised provisions 2017 Initial provisions 2018 Variation 2018/2017 (%) 05501 Training of health personnel 33.798.558 12.232.982 -64% per month 28.343.084 6.686.644 -76% 05502 Construction/rehabilitation of health facilities 20.010.259 17.800.429 -11% 05503 Purchase and maintenance of health facilities 20.089.074 18.195.826 -9% 05504 Improving the availability of quality health products 11.329.863 10.748.334 -5% 05505 Promoting health risk sharing schemes 16.219.240 16.125.742 -1% 05507 Promoting traditional medicine and pharmacopoeia 10.300 20.000 94% Total Programme 055 101.457.294 75.123.313 -26% 056 Health service delivery 05601 Community participation 28.372.483 55.191.939 95% per month 28.331.267 51.813.779 83% 05602 Reducing morbidity and mortality related to endemic/epidemic diseases 3.770.526 34.269.202 05603 Provision of quality maternal and child health services 648.617 1.550.000 139% 05604 Disaster health management 51.627 50.000 -3% 05605 Health promotion 36.598.090 2.359.529 -94% 05606 Health product quality assurance 610.414 1.566.894 157% Total Programme 056 70.051.757 94.987.564 36% 057 Department of health services’ oversight and support 05701 Ministry of Health oversight, coordination and intersector collaboration 13.571.042 17.623.612 30% per month 13.435.423 16.065.784 20% 05702 Increase in health sector financing 20.033 25.000 25% 05703 Management of financial and material resources 7.207.967 6.703.608 -7% 05704 Management of human resources 461.453 1.530.476 232% 05705 Planning, monitoring and evaluation – 43.000 0% 05706 Building/rehabilitating and equipping administrative and educational infrastructure 1.942.534 2.550.389 31% 05708 Health information 10.033 15.000 50% 05709 Health Research Promotion 879.246 1.162.702 32% 05710 Communication 118.387 30.000 -75% Total Programme 057 24.210.695 29.683.787 23% GENERAL TOTAL 195.719.746 199.794.664 2,1% Source : CID ; pour l’année 2017, état de situation tiré à partir du CID au niveau de la DAF/MS (service de l’execution budgétaire) Notes : 1. Dotations révisées : elles tiennent comptepour 2017, des deux Lois de finances rectificatives, des régulations/blocages instaurés par le MINEFID intégrés dans le CID, des modifications des crédits budgétaires au sein des programmes (dans le cadre de la fongibilité des crédits). 2. Investissement : crédits de paiement 45aPPendIxes APPENDIX 4: MINISTRY OF HEALTH’S BUDGETARY PROGRAMMES PERFORMANCE FRAMEWORK 2018-2020 Objectifs stratégique/ opérationnel Indicateurs d’impact /d’effet Référence Cibles Responsable Unité Année Valeur 2018 2019 2020 Programme 055 Accès aux sevices de santé Améliorer l’accès des populations aux services de santé de qualité Rayon moyen d’action théorique KM 2015 6,8 6,1 5,9 DGESS Pourcentage de la population vivant à moins de 5 km d’une formation sanitaire (FS) KM 2015 58,1 60 62,5 DGESS Action 05501 Formation du personnel de santé Produire des ressources humaines suffissantes et de qualité pour la santé Ration population / médecins RATIO 2016 15836 14000 13000 DRH Ratio population / IDE RATIO 2016 4108 <4000 <4000 <4000 DRH Ratio population / SFE 7778 INF7000 INF7000 INF7000 DRH Action 05502 Construction/Rehabilitation d’infrastructures sanitaires Développer les infrastructures sanitaires Pourcentage des formtions sanitaires répondant aux normes en infrastru RATIO 2016 NA 85 90 95 DGESS Action 05503 Acquisition et maintenance des équipements sanitaires Développer les équipements sanitaires et leur maintenance Pourcentage des formations sanitaires fonctionnelles selon les normes en équipements sanitaires % 2016 ND 65 70 75 DGESS Action 05504 Amélioration de la disponibilité des produits de santé de qualité Renforcer le circuit d’approvision- nement et de distribution des Produits de santé tie qualité Pourcentage des DMEG n’ayant pas connu de rupture des 20 molécules traceurs % 2016 28 DGESS Taux de rupture des MEG au niveau des DRD pour les 45 médicaments traceurseu % 2016 12,7 1,0 <1 <1 DGESS Action 05505 Promotion des mécanismes de partage des risques en matière de santé Améliorer l’accessibilité financière des populations aux services de sauté Proportion de la population couverte par un mécanisme de partage de risque maladie % 2016 12 25 30 35 DGESS Nombre de nouveaux contacts par habitant et par an NBRE 2016 1,02 1,3 1,4 1,5 DGESS 46 BUDGETING IN HEALTH Objectifs stratégique/ opérationnel Indicateurs d’impact /d’effet Référence Cibles Responsable Unité Année Valeur 2018 2019 2020 Action 05507 Promotion de la médecine et de la pharmacopée traditionnelles Renforcer la contribution de la médecine et de la pharmacopée traditionnelle a l’offre de soins de qualité Nombre de médicaments traditionnels enregistrés a la nomenclature nationale NBRE 2016 41 65 70 90 DGPML Nombre de tradipraticiens de santé autorisés a exercer NBRE 2016 29 200 250 300 DGPML Programme 056 Prestation des services de santé Réduire la morbidité , la mortalité pour une meilleure prevent°, des soins éfficaces et un changement des comportements Taux de mortalité maternelle RATIO 2016 341 243 243 243 DGESS Taux de mortalité des enfants de moins de 5 ans RATIO 2016 62,75 62,75 62,75 62,75 DGESS Action 05601 Participation communautaire Promouvoir les interventions intégrées à base communautaire en matière de santé Nbre d’ONG sous contrat de prestation avec le Ministère de la Santé NBRE 2016 252 252 252 252 DGS Nombre de villages couverts par les OBC-E NBRE 2016 8000 8000 8000 8000 DGS Action 05602 Réduction de lamobilitéet de la mortalité endémo-épidémies Promouvoir les interventions intégrées à base communautaire en matière de santé Nbre de nouveaus contacts par habitant et par an dans les structures de soins de ler échelon (CM et CSPS) NBRE 2016 1,02 1,3 1,4 1,5 DGESS Taux d’occupation des lits au niveau des hopitaux % 2016 50,5 60 65 70 DGS Action 05603 Offre de services de qualité en faveur de la santé de la mère et de l’enfant Améliorer la santé de la mère et de l’enfant Taux d’ accoucheinents assistés % 2016 80,9 >=87 >=90 >=90 DGESS Taux de réalisation des césariennes parmis les naissances attendues % 2016 >=3,5 >=3,8 >=3,9 >=4 DGESS Taux de couverture vaccinale des enfants en penta3 % 2016 103 100 100 100 DGESS Action 05604 Gestion sanitaire des catastrophes Renforcer la gestion sanitaire des catastrophes Taux de prise en charge des victimes des catastrophes % 2016 NA 80 80 80 DGS Proportion des hopitaux disposant d’un plan de riposte <plan blanc> % 2016 100 100 100 100 DGS APPENDIX 4: continued Objectifs stratégique/ opérationnel Indicateurs d’impact /d’effet Référence Cibles Responsable Unité Année Valeur 2018 2019 2020 Action 05605 Promotion de la santé Améliorer l’hygiène, I’assainissement et les comportements favorables á la santé Pourcentage de comités régionaux d’hygiène fonctionnels % 2016 ND 100 100 100 DGS Taux de réalisation physique du plan de communication en faveur de l’hygiène et de l’assainissement % 2016 >=85 >=85 >=85 DGS Action 05606 Assurance qualité des produits de santé Renforcer le système d’assurance qualité des produits de santé Taux de conformité des produits pharmaceutiques controlés % 2016 >=95 >=95 >=95 DGPML Nombre de produits controlés en post marketing NBRE 2016 339 360 370 380 DGPML Programme 057 Pilotage et soutien des services du Ministère de la Santé Renforcer les Capacités institutionnelles, organisationnelles, la gouvernance et le leadership dans le secteur de la santé Proportion des structures disposants de tous les outils de pilotage et de bonne et goouvernance % 2016 ND 100 100 100 Cab. Min. Action 05701 Pilotage, coordination des actions du Ministère de la Santé et collaboration intersectorielle Améliorer le pilotage stratégique des actions du Ministère de la santé et la collaboration intersectorielle Taux de réalisation des revues du secteur de la santé % 2016 100 100 100 100 Cab. Min. Nombre de CASEM santé tenus NBRE 2016 2 2 2 2 DGESS Action 05702 Accroissement des financements du secteur de la santé Mobiliser les financements au profit du secteur de la santé Taux de mobilisation des ressources additionnelles % 2016 ND >=90 >=90 >=90 DAF Taux d’absorption des ressources financières allouées % 2016 94,22 >=87 >87 >=88 DAF Proportion du budget de l’Etat allouée au Ministère de in Santé % 2016 12,4 13,5 14 14,5 DAF Action 05703 Gestion des ressources financières et matérielles Améliorer la gestion des ressources financières et matérielles mobilisées Pourcentage des structures ayant fait l’objet d’audits financiers % 2016 ND 100 100 100 SG Nombre d’inventaires de matériels realisés NBRE 2016 ND 2 2 2 DAF APPENDIX 4: continued Objectifs stratégique/ opérationnel Indicateurs d’impact /d’effet Référence Cibles Responsable Unité Année Valeur 2018 2019 2020 Action 05704 Gestion des ressources humaines Rationnaliser la gestion des ressources humaines pour la santé Pourcentage de CSPS remplissant les normes minima en personnel % 2016 93,2 >=95 >=95,3 >=96 DGESS Action 05705 Planification, suivi et évaluation Améliorer le processus de planification de suivi et d’évaluation au sein du secteur de la santé Proportion de structures disposant d’un plan d’action annuel % 2016 100 1000 100 100 DGESS Taux d’exécution physique des plans d’action % 2016 ND >=85 >=85 >=85 DGESS Action05706 Construction/réhabilitation et équipement d’infrastructures administratives et éducatives Développer les infrastructures administratives et éducatives, et leurs équipements Pourcentages des ECD fonctionnelles selon les normes en infrastructures % 2016 ND 100 100 100 DGESS Pourcentage des infrastructures éducatives publiques conformes aux normes % 2016 ND 90 90 90 DGESS Action 05708 Information sanitaire Développer l’information sanitaire Taux de promptitude des rapports d’activités des Formations Sanitaires publiques de soins % 2016 ND >=85 >=85 >=85 DGESS Taux complétude des rapports d’activités des Formations Sanitaires publiques de soins % 2016 97,1 100 100 100 DGESS Action 05709 Promotion de la recherche pour la santé Développer la recherche pour la santé Proportion de protocoles d’études et de recherches validés par un comité d’éthique ayant fait l’objet d’un rapport % 2016 ND 100 100 100 DGESS Proportion des résultats de recherches utilisés dans le processus de prise de décision % 2016 ND 60 65 70 DGESS Action 05710 Communication Améliorer la communication pour le changement de comportement des population Taux de réalisation physique annuel du plan de communication en faveur de l’hygiène et de l’assainissement % 2016 ND >85 >85 >85 DGS Source: Budget – expenditure, Ministry of Health. Note: an error has crept into the strategic objective for action 05602: Reducing endemic/epidemic morbidity and mortality should in fact be “Improve the supply of quality health services”. APPENDIX 4: continued For additional information, please contact: Health Systems Governance and Financing Department Universal Health Coverage and Health Systems Cluster World Health Organization 20, avenue Appia 1211 Geneva 27 Switzerland Email: healthfinancing@who.int Website: http://www.who.int/health_financing HEALTH FINANCING CASE STUDY No 11 BUDGETING IN HEALTH

Hélène Barroy Françoise André Abdoulaye Nitiema TRANSITION TO PROGRAMME BUDGETING IN HEALTH IN BURKINA FASO: STATUS OF THE REFORM AND PRELIMINARY LESSONS FOR HEALTH FINANCING HEALTH FINANCING CASE STUDY No 11 BUDGETING IN HEALTH Hélène Barroy Françoise André Abdoulaye Nitiema TRANSITION TO PROGRAMME BUDGETING IN HEALTH IN BURKINA FASO: STATUS OF THE REFORM AND PRELIMINARY LESSONS FOR HEALTH FINANCING HEALTH FINANCING CASE STUDY No 11 BUDGETING IN HEALTH Transition to programme budgeting in health in Burkina Faso: Status of the reform and preliminary lessons for health financing / Helene Barroy, Françoise André, Abdoulaye Nitiema WHO/UHC/HGF/HEF/CaseStudy/18.11 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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Barroy H, André F, Nitiema A: Transition to programme budgeting in health in Burkina Faso: Status of the reform and preliminary lessons for health financing. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third- party-owned component in the work rests solely with the user. General disclaimers. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Printed in Switzerland. TABLE OF CONTENTS Acknowledgements ....................................................................................................................................................v Executive Summary ..................................................................................................................................................vi Introduction .................................................................................................................................................................1 1. Context of the reform ................................................................................................................................ 3 1.1 Changes to the subregional regulatory framework .................................................................. 3 1.2 Change to Burkina Faso’s legislative and regulatory framework ......................................... 5 1.3 Changes within the health financing system and alignment with public financial management reforms .......................................................................................................................... 7 2. Process of transition to the programme budget .......................................................................11 2.1 Programme budget: from preparation to institutionalization for all ministries (1998-2015) .........................................................................................................................11 2.2 The Ministry of Health’s transition to a programme budget: alignment with national health strategies ....................................................................................................... 14 2.3 Changing role of stakeholders in the reform .............................................................................16 3. Structure and content of the Ministry of Health’s budgetary programmes .............. 19 3.1 Structure of the Ministry of Health’s programme budget .................................................... 19 3.2 Analysis of the content of the Ministry of Health’s budgetary programmes ............... 20 3.3 Implications of the reform for specific health projects (immunization, HIV/AIDS, malaria, tuberculosis) .....................................................................................................23 4. First effects of the reform (2017-2018): progress and challenges .................................. 26 4.1 Moving towards an end to annual deferred budgetary programmes? ........................... 26 4.2 Towards more flexibility in spending? ..........................................................................................27 4.3 Towards financial accountability that is of benefit to the sector? ..................................... 30 Summary of progress, challenges and recommendations .............................................................. 31 Bibliography ................................................................................................................................................................33 Appendixes................................................................................................................................................................ 41 Appendix 1: Budget-planning process since the adoption of the programme budget .............. 41 Appendix 2: List of the Ministry of Health’s programme budget’s actions and activities ........ 42 Appendix 3: Variation in allocations by programme and action between 2017 and 2018 ........44 Appendix 4: Ministry of Health’s Budgetary programmes Performance Framework 2018-2020 .............................................................................................................45 List of tables Table 1: Summary of the WAEMU Harmonized Public Financial Management Framework .......4 Table 2: Key aspects of budget reform agenda in Burkina Faso ........................................................... 5 Table 3: Main items related to planning and implementation of reform plans and sector finance strategy ........................................................................................................................6 Table 4: List of purchasers and payment methods used..........................................................................8 Table 5: Health financing strategy: challenges and remedial action for public expenditure on health........................................................................................................................10 Table 6: Extract of the structure of the line budget, Ministry of Health (before 2017) ............... 15 Table 7. Alignment between the new budgetary programmes and the Ministry of Health’s reorganization (2018) .........................................................................................................17 Table 8: Ministry of Health’s programme budget’s programmes and actions (2018) ..................22 Table 9: Allocation of pre-reform and post-reform immunization expenditure ...........................24 Table 10: Actions and activities posted under the Presidency’s “Fight against HIV, AIDS and STDs” budget plan ...........................................................................................................25 Table 11: Budget allocation of malaria prevention and management expenditure in the programme budget (post-reform) .........................................................................................25 Table 12: Implementation of the health budgetary programmes (2017) ........................................... 28 Table 13: Extract from the Ministry of Health programme budget’s Performance Monitoring (2018-2020) ................................................................................................................... 29 List of figures Figure 1: History of the transition to the programme budget in Burkina Faso ............................... 12 Figure 2: Mapping of 2011 PNDS objectives, 2011-2018 Ministry of Health budgetary programmes and 2016 PNDS objectives .....................................................................................16 Figure 3: Structure of the Ministry of Health’s budgetary programmes in Burkina Faso .......... 20 Figure 4: Distribution of budget appropriations by programme in 2017 and 2018, Ministry of Health ................................................................................................................................27 v ACKNOWLEDGEMENTS The report was written by Hélène Barroy (WHO Governance and Health Financing Department), Françoise André (Public Financial Management consultant, WHO), and Abdoulaye Nitiema (Director, Studies and Statistics, Ministry of Health, Burkina Faso). It is the result of data collection and analysis work conducted by Hélène Barroy, Françoise André and Mathurin Koné (WHO consultant, public finance) in Burkina Faso between January and March 2018. Input was also provided by the WHO country office, in particular by Dr Alimata Diarra (Burkina Faso Representative), Dr Fatimata Zampaligré (health systems focal person), Dr Seydou Coulibaly (Intercountry Support Team, IST-WA) and Alexis Bigeard (Intercountry Support Team, IST-WA). We are grateful for their contributions. The authors would also like to thank the WHO African Regional Office, in particular Dr Grace Kabaniha, for their support in the successful conduct of the study. The analysis was performed in close collaboration with the Burkinabe government authorities. The authors wish to extend their heartfelt thanks to the following individuals from the Ministry of Health and the Ministry of the Economy, Finance and Development for their valuable technical contributions to this study: For the Ministry of Health: S.E. Dr Nicolas Méda, Minister of Health, Dr Hidnibba Francine Ouedraogo, Secretary general at the Ministry of Health, Dr Sylvain Dipama, Technical adviser at the Ministry of Health, Dr Isaie Medah, Director general of public health, Dr Samba Dialllo, Director general of health care provision, Dr Pierre Yameogo, Technical secretary of universal health coverage, Mr Daouda Akabi, Director of administration and finance, Dr Yacouba Sawadogo, Coordinator of the National malaria control programme and their teams. For the Ministry of Finance, Economy and Development: Ms Brigitte Compaore, Deputy director general of the budget, Mr Vincent de Paul Yameogo, Director of budget reform. The authors also wish to thank Fadhi Dkhimi (WHO) and Alexis Bigeard (WHO) who reviewed the report, as well as the local partners consulted during the conduct of the study, in particular the European Union (Bart Callawaert), WAEMU (Issa Sawadogo) and the World Bank (Bali Ouattara, Benoit Mathivet). The conclusion of this report were shared, discussed and formally revised by the authorities of the Ministry of Health of Burkina Faso during the seminar organised in Ouagadougou by the Ministry of Health and the WHO on programme-based budget in health on 11-12 July 2018. The study was funded with support from GAVI’s Sustainability Strategic Focus Area initiative and DFID’s Making Country Health Systems Stronger programme. vi BUDGETING IN HEALTH EXECUTIVE SUMMARY The critical role of budget formulation in optimising sector performance is often overlooked by many actors within the health sector. Determining the most effective allocation and flow of resources within the health system remains a central question for the public expenditure (and thus the performance) in this sector. Since the end of the 1990s, Burkina Faso (a French- speaking West African country) has initiated a profound reform relating to the management of public finances, in line with regulations set by the West African Economic and Monetary Union (WAEMU). One flagship measure within this reform was the introduction of a programme budget, marking a shift away from a purely input based budget. Institutionalizing this reform in Burkina Faso took twenty years, with the adoption by Parliament in 2017 of a budget presented according to a programme based approach - the first in the WAEMU region. The Ministry of Health was one of the first pilot ministries to engage in this reform and achieve the transition to institutionalization, by consolidating a budget around three major budget programmes that aligned with the National Health Plan, i.e. the Plan National de Développement Sanitaire (PNDS). Burkina Faso‘s shift to a programme budget for health offers interesting lessons for other countries engaged in similar reforms. In particular, by studying the process and impact of this reform, we highlight the following elements related to the definition and effective implementation of the programme budget in the health sector: Defining the content of budgetary programmes is a central issue for the health sector. Harmonizing budgetary programme content with the sector’s priorities requires strong mobilization of sectoral actors in coordination with financial actors, in order to define the first budgetary programmes and their subsequent periodic reviews; The programmatic budget formulation reduces financial fragmentation resulting from previous input budgeting, and also creates scope to further reduce financing duplication and fragmentation by integrating “disease” interventions into broader budgetary programmes; To be complete, the reform involves a transition process across several levels. Along with reforms relating directly to public finance, legal aspects (such as updating the regulatory framework) as well as institutional aspects (such as strengthening sectoral capacities in budgetary planning) should be addressed with priority; The reform goes beyond a change in budget formulation by requiring improved expenditure management. It also lays the foundations for more flexible spending that can be adapted to sector changes when needed, and allows for reallocation within budget programmes; When accompanied by a quality performance monitoring framework, the programme budget makes it possible to set up performance monitoring, combining financial/budgetary and operational/programmatic aspects in a single framework. If policy makers use the performance information, a unique opportunity to guide future budget decisions in an efficient manner arises. While Burkina Faso is advanced in budget programme implementation, particularly in the health sector, some challenges remain. In 2018, the Ministry of Health rightly initiated a review of the content and contours of the two main budget programmes, in order to bring them into line with vii the department’s new strategic directions and to improve their overall quality. The definition of a more relevant performance-monitoring framework is also a key aspect to be strengthened. In parallel, building the capacity of newly appointed Programme Directors and their teams in programme budgeting seems essential for ensuring better involvement in programme definition, and thus coherence in their implementation. Strengthening the links between budget reform and health financing strategy, notably the creation of the Health Insurance Scheme (RAMU), also needs close monitoring by decision-makers in order to ensure coherence and coordination. 1IntroductIon INTRODUCTION Most countries around the world have begun a transition to programme or objective- based budgets to improve their alignment with public policy priorities and to meet the need for accountability and transparency expressed by many parliaments and citizens.1 In addition to changes in the presentation of budget documents, this reform involves major changes in the budgeting and expenditure management system requiring closer collaboration between finance and line ministries. In the health sector in particular, it is not easy to identify the outlines and content of budgetary programmes. While this reform has the potential to improve the organising of funds according to sector priorities/ objectives, it requires the health authorities’ consideration during the preparation phase so that it may deliver the expected benefits to the sector. Development partners, including those involved in the health sector, are also relatively unaware of this transition and a better understanding of its implications is needed. Against this background, in 2018, the World Health Organization’s (WHO) Department of Health Systems Governance and Financing began a work programme on health budget structure issues to produce more information on the process and the effects of health budget reform and to offer more support to countries undergoing reform. This work programme is divided into three principal areas: 1. A global review of health budget structures; 2. Case studies on the transition to programme budgets in the health sector; 3. Training and support for health budget reform.2 Burkina Faso was identified as one of the first countries to be studied in the WHO African Region. Having completed a pilot phase, Burkina Faso was the first WAEMU country to have institutionalized programme budgets, i.e. a budget created for all the ministries in 2017 around major public policy objectives and priorities. Having made progress with this transition, WHO has chosen Burkina Faso for this study to identify the preliminary lessons learnt from the experiment and to share these lessons with other countries in the subregion and beyond. The study’s specific goals were to analyse the structure of the health budget before and after the reform; to document the process of transition from a line budget to a programme budget, focusing on specific projects such as immunization; to analyse the initial effects of the reforms from a sector perspective; and to identify useful recommendations for any changes to the country’s reforms. The study began with a document review, including of the literature and budgetary and legal documents, followed by data collection in the country and interviews with key stakeholders in the health and finance sectors between January and March 2018. The results were shared with the Ministry of Health authorities in May 2018 and reviewed and approved in July 2018. The report begins with a contextual review of the developments in the WAEMU regulatory framework and its transposition into national law with respect to the programme budget and public financial management more generally. A review is also conducted of the 2 BUDGETING IN HEALTH developments in health financing and their links to public finance. The second part of the study report focuses on the budget reform process, analysing the various stages in the transition, including in the health sector, and the various players’ roles in the reform. The third part deals more specifically with the structure and content of the Ministry of Health’s three budgetary programmes and, at the request of the partners supporting and involved in this study, contains an analysis of the implications of the reform with respect to the inclusion of specific interventions – such as immunization, HIV/AIDS, malaria, tuberculosis – in the new budget formulation. The last section of the report analyses the initial impact of the reform on budget planning, flexibility in managing expenditure and accountability. The study concludes with a summary of the progress and challenges of the reform and highlights some key recommendations on adapting the reform to best address the needs of the sector in Burkina Faso. 3context of the reform In 2009, following discussions that had been held since the early 2000s, the West African Economic and Monetary Union (WAEMU) agreed to a harmonized public finance framework applicable to all its member states. Some of this reform’s flagship measures included introducing results-based management and a programme budget tool. Having transposed the whole regulatory and legislative framework required by WAEMU into its own legislation between 2013 and 2016, Burkina Faso adopted the first “programme budget” in 2017.I It was therefore the first WAEMU country to shift to this approach. At the same time, certain aspects of the discussions that had been initiated on health financing and its considerable implications for public financing levels and streams, were conceived in conjunction with public financial management reforms. 1.1 CHANGES TO THE SUBREGIONAL REGULATORY FRAMEWORK In 2009, the WAEMU countries adapted the Harmonized Public Financial Management Framework drafted in the late 1990s to international standards and best practice in public financial management. In 2009, the I In Burkina Faso, the word “programme budget” has officially been adopted and will be used in the rest of this report. WAEMU Council of Ministers adopted six directives (Table 1). The aim of this new regulatory framework was to ensure better outcomes and more effective public policies. It laid down new rules on modernizing budgetary management and introduced budgetary discipline that facilitated sustainable budgetary policies and more efficient public resources, set within a framework of major budgetary constraints. It also aimed to strengthen the link between national development strategies, sector policies and the state budget. Finally, it established a results-based culture by giving the “operational” staff responsibility for the results achieved and introducing greater clarity, transparency and effective accountability in the management of public affairs. The transition to a programme budget is one of the key elements of the WAEMU Finance Law Directive (No. 06/2009). In Section III, Article 12, “Content of the year’s finance laws”, the directive specifies that “within ministries, appropriations are broken down into programmes[...].” The article defines a programme as “consolidating the appropriations set aside to implement an action or a coherent set of measures that represent a clearly defined medium- term public policy.” These programmes are combined with “specific goals, agreed on the basis of public interest and expected outcomes.” These outcomes, “measured by performance indicators, are regularly evaluated and embodied in an [annual] performance report.” 1. CONTEXT OF THE REFORM 4 BUDGETING IN HEALTH Transcribing the Directives into national law varies according to the state and directive. The WAEMU member states had committed to transposing the directives into their national legislation in December 2011, with a deadline of January 2017 for full implementation of the programme budget provisions. Following a decision of the WAEMU Council of Ministers in April 2017, this deadline was extended to 1 January 2019.II II Press release of the Ordinary Session of the Council of Ministers of the Union, Dakar, 31 March 2017 “The Council examined the status of implementation of the Directives of the Harmonized Public Financial Management Framework on 31 December 2016 (...). With respect to the states’ implementation of these reforms, the Council invited the Ministers of Finance to complete the implementation of the directives and in particular the implementation of the programme budget by 1 January 2019 at the latest.” However, national decisions appear to have set other extensions. In December 2016, Senegal’s National Assembly therefore voted to postpone the date the Institutional act on finance laws will come into effect to 1 January 2020. While Burkina Faso was among the first of the member states to transpose the Transparency Code (after Senegal, which did so in December 2012), it was the last to do so for the Finance Law and the decrees pursuant to it. Even though other countries have indeed amended their regulatory framework more swiftly, implementation is very uneven between states. By the end of 2016, only Burkina Faso had decided to adopt a budget according to the programme-budget format for the 2017 fiscal year, in line with the deadline initially set by WAEMU. For 2017, the other member states had planned implementation in some ministries (Benin, Côte d’Ivoire, Mali and Senegal) or future implementation in the state budget (2018 in Niger or 2019 in Togo).4 Table 1: Summary of the WAEMU Harmonized Public Financial Management Framework Directives of the WAEMU Harmonized Public Financial Management Framework Main guidelines of the Directives Directive No. 01/2009/CM/WAEMU of 27 March 2009 on the Code of transparency in public financial management in WAEMU General umbrella directive for five others, which establishes the principles and obligations that the member states must respect on managing government and other government departments’ funds in their legislation and practice. Directive No. 06/2009/CM/WAEMU on Finance laws in WAEMU Sets out the rules on the scope and classification of the Finance laws, their content, presentation, macroeconomic framework, preparation and votes, as well as the implementation and checks on the Finance laws and, finally, the transitional provisions. Directive No. 07/2009/CM/WAEMU on the General regulations on public accounting in WAEMU Sets out the rules governing the management of public accounts, securities or assets. Directive No. 08/2009/CM/WAEMU on the government budget classification in WAEMU Sets out the basic rules and principles for presenting budget operations. Directive No. 09/2009/CM/WAEMU on the government chart of accounts in WAEMU Lays down the basic rules for the accounting of financial and budget operations in the member states. It determines the aim of the general accounting, the standards, rules and procedures on keeping and producing the state’s accounts and financial statements. Directive No. 10/2009/CM/WAEMU on the government financial operations table in WAEMU Specifies the general principles on the drafting and joint presentation of statistics on the state’s financial operations that form the basis of multilateral monitoring. Source: WAEMU, 2009 5context of the reform 1.2 CHANGE TO BURKINA FASO’S LEGISLATIVE AND REGULATORY FRAMEWORK Burkina Faso has made a considerable effort to update and strengthen its legislative and regulatory framework on public finance. All laws and decrees were adopted between 2009 and 2015-2016, providing a complete and up-to-date regulatory framework for WAEMU directives (Table 2). The adoption of this regulatory framework, brought into line with the 2009 WAEMU Directives, follows on from the comprehensive approach initiated in the country in the early 2000s. As soon as the Plan of action to strengthen budget management was drafted and adopted in July 2002, Burkina Faso began a process of reform and modernization of its budgetary systems based on a results- based management (RBM) approach. This commitment is reflected in the Strategy to strengthen public finance, adopted in April 2007 and in the Economic and financial sector policy for 2011-2020 (see Table 3). The guidelines on results-based management are laid down within these frameworks. To improve the planning of resources, from 2001, the authorities introduced the Medium- Term Expenditure Framework (MTEF) setting out budget allocations (“envelopes”) for each ministry by inputs (e.g. operations, personnel, goods and services, and transfers).III The MTEF is updated every year to follow the macroeconomic forecasts as closely as possible. III The goals of the global MTEF are: (1) to define a coherent and realistic multi-year resource framework based on an accurate macroeconomic framework, (2) to identify medium-term sectoral financial budgets aligned with the Government’s strategic priorities and budgetary constraints, and (3) to ensure a predictable financial framework for ministries to develop and implement strategies and achieve the expected results. Table 2: Key aspects of budget reform agenda in Burkina Faso Directives of the WAEMU Harmonized Public Financial Management Framework Burkina Faso – National legislative and regulatory transposition Directive No. 01/2009/CM/WAEMU on the Code of transparency in public financial management in WAEMU Law No. 008-2013/AN of 23 April 2013 on the general code of transparency in public financial management in Burkina Faso Directive No. 06/2009/CM/WAEMU on Finance laws in WAEMU Institutional act No. 073-2015/CNT of 06 November 2015 on finance laws, which came into effect on 1 January 2016 Directive No. 07/2009/CM/WAEMU on the general public accounting regulations in WAEMU Decree No. 2016-598/PRES/PM/MINEFID of 08 July 2016 on general public accounting regulations Directive No. 08/2009/CM/WAEMU on the government budget classification in WAEMU Decree No. 2016-600/PRES/PM/MINEFID of 08 July 2016 on the government budget classification Directive No. 09/2009/CM/WAEMU on the government chart of accounts in WAEMU Decree No. 2016-601/PRES/PM/MINEFID of 08 July 2016 on the conceptual framework for public sector accounting Directive No. 10/2009/CM/WAEMU on the government financial operations table in WAEMU Decree No. 2016-602/PRES/PM/MINEFID of 08 July 2016 on the government financial operations table Source: WAEMU, 2009 and Burkina Faso, www.legiburkina.bf5 6 BUDGETING IN HEALTH In addition to changes that affect budget planning, public finance reforms have an impact on expenditure practices, namely by introducing the principle of “decentralizing authorization” (Article 70, Institutional act on finance laws – LOLF). This approach translates into a transfer of certain prerogatives from the Minister of Finance, previously the sole primary authorizing officer, to the sector ministers (and thus the Health Minister), who become the chief authorizing officers for their ministries’ appropriations. The sector minister therefore has direct responsibility for their ministry’s expenditure as they proceed with the respective commitments (authorize expenditure) and settlement (approve payment) of the appropriations. The ministers who authorize spending can then delegate their powers within the Ministry (Article 67), and specifically to programme managers for appropriation commitments.IV Besides decentralizing the authority to authorize expenditure, the sector ministries are now responsible for various controls that IV In the Ministry of Health, the commitment is delegated to the Department of financial affairs (DAF) and may subsequently be transferred to the programme managers; the “Cellule d’ordonnancement” is responsible for the authorizing (currently still within the Ministry of the Economy, Finance and Development but which will be transferred to the sector ministry). Table 3: Main items related to planning and implementation of reform plans and sector finance strategy Plan of action to strengthen budget management 2002-2006 Strategy to Strengthen Public Finance 2007-2015 Economic and financial sector policy 2011-2020 Budget planning Strengthen the quality and transparency of the Finance Law (with an emphasis on frameworks for medium-term expenditure and results-based management (RBM)) - Transparent and efficient public expenditure management process - Plan expenditure according to the strategic allocation principle and results-based budgeting - Strengthen stakeholder accountability - Results-Based Management and introduction of Programme Budget approach - Strengthen consistency of the macroeconomic framework, medium-term fiscal plans and budget allocations - Adjust tools to the Results-Based Management approach and the Programme Budget - Support in sector public policy-making - Bring the legislative and regulatory framework in line with WAEMU directives - Capacity building of budget management stakeholders according to the PB approach Budget implemen- tation Strengthen the monitoring of budget implementation (system and data) - Transparent and efficient public expenditure management process - Strengthen stakeholder accountability - Complete and reliable budget implementation data - Develop statistical output - Adjust the I.T. system to the PB - Improve the spending flow by creating verification units in sector ministries along with the flow in terms of procedure and participants Controls Strengthen controls on the implementation of the budget Efficient monitoring system aligned with international standards Consideration/further development of the monitoring system in principle and adjusting it to PB requirements Sources: Plan of action to strengthen budget management and Strategy to strengthen public finance from “Evaluation of Public Financial Management Reform in Burkina Faso, 2001–2010, DANIDA, Final Country Case Study Report, June 2012”6; Economic and financial sector policy: Ministry of the Economy and Finance, Economic and Financial Sector Policy 2011-2020, Economic and financial sector policy 2011-2020, April 20117 7context of the reform will take place at different stages in the chain of expenditure. Government expenditure verification unitsV were set up in the ministries in 2012 to free up the central monitoring departments, reduce the time taken to authorize the expenditure and also to support the decentralization of authorizations and the development of authorizing officers’ and their teams’ responsibilities.VI The other principle governing public expenditure is the principle of “asymmetric fungibility” introduced in Burkina Faso by the institutional act of 2015. According to this principle, spending, can vary upwards or downwards, within each budgetary programme ceiling. Wage expenditure, remains under control: it can only fall (not rise), while capital expenditure can only rise, hence the “asymmetry”. This principle is supposed to apply to each budgetary programme, providing a larger autonomy to the Ministry, but somehow contradicts a programme model that would enable full flexibility on all items of expenditure within the same programme.VII V The units are responsible for verifying and validating the expenditure, from the administrative phase through to the payment; a verification unit is made up of a “Financial Check” cell, an “Authorizations” cell and a “Payments” cell, which are hierarchically and operationally linked to the parent organization, namely the Ministry of the Economy, Finance and Development’s Office of public procurement and financial commitments, Office for scheduling and accounting and Public accounting office and treasury respectively. VI In accordance with the WAEMU directive, the LOLF enshrines the increased powers of the Minister of Finance through regulatory powers, which enables them to maintain the budgetary and financial balance stipulated in the current Finance Act, cancel appropriations and make the authorizing officers’ use of appropriations subject to the availability of cash (Art. 69). VII Fungibility (LOLF, Art. 17, section 2): “... within the same programme, the authorizing officers may amend the type of current appropriations and use them, if they are free to do so, in the following cases: – staff appropriations to increase appropriations for goods and services, transfer or investment line items; – appropriations for goods and services and transfers to increase investment appropriations.” 1.3 CHANGES WITHIN THE HEALTH FINANCING SYSTEM AND ALIGNMENT WITH PUBLIC FINANCIAL MANAGEMENT REFORMS Along with reforms to public financial management, in 2010, the country began a review aimed at changing the health financing system. Between 2013 and 2017, the Ministry of Health developed a health financing strategy (2017-2030)8, which was presented to the Council of Ministers in June 2017.VIII In 2015, public and external funds accounted for 33% and 22% of total current health expenditure respectively9. Between 2015 and 2016 though, the share of direct payments went down from 36% to 31% of total health expenditure, a noticeable decrease most likely attributable to the user fee removal policy. Half of public expenditure is financed by external funds (on average 47% of public health expenditure between 2012 and 2015). In absolute terms, budgetary provisions have nearly quadrupled in 10 years, rising from around 34 billion CFA francs in 2005 to 132 billion in 2014 (and 180 billion in 2016). As a share of total public expenditure, health expenditure remained relatively stable between 2012 and 2015, averaging 12% over the period. Burkina Faso is one of the countries in the African region that has VIII The financing strategy (October 2017 version) is available but has not been formally adopted by the Government. Following a review by the Council of Ministers, the hope is to develop an operational plan based on this strategy, enabling progress to be made towards concrete implementation. In November 2018, the operational plan was finalized and submitted to the Cabinet for approval. 8 BUDGETING IN HEALTH historically given high priority to the health sector in its public spending. In the past, the health financing system has been characterized by highly fragmented funding systems. Mapping conducted in 201410 shows around 30 schemes, most of which are attributable to the free programmes set up since 2006. Two funds cover a very limited range of health services for employees in the formal private sector (National social security fund – CNSS) and civil servants (Civil servants’ pension fund – CARFO)IX. According to a 2011 study, community-based health insurance in Burkina Faso comprises around IX CNSS package includes : maternal and child health services, HIV/Aids treatment and sanitary evacuation for treatment abroad. CARFO extended coverage in 2009 to provide medical and surgical assistance, and care and treatment in case of work accidents. 200 entities, of which 188 are in operation.X These “mutuelles” cover a total of 140,000 beneficiaries (fewer than 1,000 beneficiaries per entity), and the services that are covered are generally part of the minimum and complementary health care package in first and second-level health facilities. The payment system for health services encompasses a range of methods, due on the one hand to the fragmentation of the schemes and on the other to the use of multiple payment systems for the same scheme. The table below, drawn up as part of the WHO X According to a 2011 study, these include 131 community- based health insurance (“mutuelles”), 38 professional “mutuelles”, 22 other cost-sharing schemes, 9 other prepayment schemes and 5 village solidarity funds (ASMADE. Inventory of mutual societies for universal health coverage in Burkina Faso, October 2011)11. Table 4: List of purchasers and payment methods used Overall budget allocation Allocation by budget item Payment by procedure Payment on a case-by- case basis (flat rate) Capitation Payment by results Ministry of Health – DAF X X       Ministry of Health – Health development programme X X X Ministry of the Economy, Finance and Development/Ministry of Territorial Administration and Decentralization/Ministry of Health X Generic medicines purchasing agency           X National council for the fight against HIV/AIDS and sexually- transmitted infections X NGO X X X X     Mutual health insurance X Private insurance     X       Universal health insurance scheme       X  X   TFPs (regulated) X X Source: WHO, 201712 9context of the reform study on payment for health services, maps the various existing mechanisms.12 The overall goal of the new health financing strategy is to “remove barriers to access to health care.” To achieve this, it lists 17 key measures to address the challenges that have been identified. One of the key measures is the implementation of a universal health insurance scheme – RAMU, which still needs to be outlined. This would be a mandatory pre-financing system, subsidized with public funds. Coverage of the formal public and private sector is identified as a priority; the informal sector is planned to be covered through community-based health insurance schemes, although the terms have yet to be defined. Another key issue being discussed pertains to aligning the RAMU with existing funding systems, particularly those for free care programmes, which could be incorporated in the universal health insurance scheme. Many of the challenges identified in the health financing strategy and the associated arrangements relate to improved management of public resources in the sector, with a clear link being drawn to reforms in the management of public finance. The strategy also identifies the implementation of Results-Based Management, and the programme budget, as a tool for improved “oversight/governance/monitoring of the sector’s financing system” (see Table 5). This alignment between public finance and health financing reform must be highlighted as positive. Another reform – decentralization – is linked to the public financial management reforms and directly affects the health sector. The reform, which began in 200413 provides for the transfer of skills and resources from the state to the municipalities for level 1 facilities (health centres – Centre de Santé et de Promotion Sociale)14, while the regions are assigned jurisdiction over health centres with surgical units,15 corresponding to level 2. This involves a transfer of skills to build and comprehensively manage these health facilities, including the staff, for minimum (first level) and complementary (second- level) packages. This reform has several implications from a sector financing point of view. The transition to the programme budget involves grouping two types of transfers for the municipalities under a single government “transfer of resources to local and regional authorities” programme and “transfer to the health sector” action. The Ministry of Health in principle no longer manages the subsidies to operate and invest in first-level health facilities.XI In practice, however, only skills, and therefore resources, are transferred to the municipalities as there is no transfer to the regions. The human resources associated with the delivery of minimum and complementary care packages should also be transferred to lower levels, but this part of the policy has not been implemented to date, owing to resistance from the Ministry’s staff, currently part of the civil service. Discussions have been under way since 2017, with plans to create a hospital XI These funds are subject to two interministerial orders (Ministry of the Economy, Finance and Development/ Ministry in charge of decentralization and Ministry of Health) on the allocation of transferred financial resources, and orders drafted by the Ministry of Health DAF (based on the Directorate general of sector studies and statistics proposals), prior to being sent to the Ministry of the Economy, Finance and Development’s General directorate for regional development (DGDT) for their operational implementation and transfers at the start of the year. One relates to funds earmarked for investments in buildings to standardize basic health facilities and the other, sums intended for recurring costs in basic health facilities. 10 BUDGETING IN HEALTH public service, a body separate from the national civil service, but which all the jobs in health facilities could be linked to. Under the programme budget, staff costs are charged to the Ministry of Health’s various programmes (see section 4.2) but are still implemented, for remuneration, by the Ministry of the Economy, Finance and Development. Table 5: Health financing strategy: challenges and remedial action for public expenditure on health Task Challenges Measures Mobilizing resources Capacity of the Ministry of Public Health to monitor the overall health budget System for mobilizing and monitoring financial flows for the whole sector Ensure appropriate financing of the sector Allocate 12% of the health budget Ensure financing of the various schemes, possibly subsidized (universal health insurance scheme and free schemes) Universal health insurance scheme subsidy plan Pooling resources/strategic purchasing Implement decentralization Municipal financing plan Optimize and align appropriations centrally Delegated appropriation targeting plan Allocation of appropriations Set up a strategic purchasing team Oversight/governance/ monitoring Alignment between planning and financing needs Results-based management (programme budget) Actual availability of financial resources in health facilities and flexibility in managing funds Review of provisions related to health facilities’ use of resources Source: Health Financing Strategy, Ministry of Health, 201710 11Process of transItIon to the Programme budget A transition process that lasted almost two decades led to a programme budget being institutionalized and adopted by the Parliament of Burkina Faso in 2017. For the health sector, the long phase of preparation and oversight (1998-2015) enabled a favourable technical, legal and institutional environment to be established. During this period, a programme budget was prepared specifically for the Ministry of Health, to complement the input line budget, and the objectives/programmes were aligned with the 2011-2020 National Health Development Plan. In 2018, under the leadership of a new Minister, the Ministry of Health began a process of reformulating the health sector budgetary programmes to bring them more in line with a new vision for the sector, placing prevention and universal access to services at the core. During the process, the Ministry of Health took ownership of the reform, seeing an opportunity for better alignment between the budget and the sector’s priorities. 2.1 PROGRAMME BUDGET: FROM PREPARATION TO INSTITUTIONALIZATION FOR ALL MINISTRIES (1998-2015) The programme budget approach was first introduced in Burkina Faso in 1997.16 From 1998, six pilot ministries, including health, were identified for implementation of the programme budget. In 2000, the approach was extended to all ministries and institutions who were now required to prepare a programme budget alongside/in addition to their line budgets. However, in the absence of suitable reference systems and frameworks until approximately 2005, there was little consistency in the documents being prepared. From 2005, the country worked to frame and formalize the process, which was expedited in 2010. Closer oversight was implemented by creating different governance entities within the Ministry of Finance with contacts in the sector ministries. The technical framework was also developed by producing benchmarks that offered guidance on preparing programme budgets, particularly in the six ministries previously identified as pilots. From 2010 to 2016, the country entered a pre-institutionalization phase with the aim of meeting the deadlines set by WAEMU (initially planned transition in 2017). As mentioned above (section 1), the legislative and regulatory framework was updated between 2013 and 2016. The regulations, in line with international recommendations, include accurate information on the number and structure of the budgetary programmes (a maximum of 7 programmes, 10 actions per programme and 40 activities per action in each ministry).17 Support for sector ministries has been accelerated through training, along with adjustments to expenditure management and monitoring tools (See Box 1). Immediately after the 2016 presidential circular that instructed a shift in the 2017 2. PROCESS OF TRANSITION TO THE PROGRAMME BUDGET 12 BUDGETING IN HEALTH budget law was adopted, the programme budget became mandatory and was the only budget presented for all the ministries in 2017. The Budget law adopted by Parliament in 2017 is set out according to 127 programmes and provisions for the 39 ministerial departments and institutions.XII XII The appropriations not allocated to programmes were divided into provisions, comprising a set of appropriations to cover expenditure that could not be directly linked to public policy objectives (Institutional act, Art. 16). Figure 1: History of the transition to the programme budget in Burkina Faso Source : Authors 1998: launch of the programme budget as an exercise for pilot ministries 2010-2015: strengthening the technical, legislative and institutional environment 2017: first official programme budget adopted by Parliament Activity 2016: Presidential memorandum officially establishing the programme budget in 2017 2000-2005: expanding the programme budget to all ministries INSTITUTIONALISATIONPREPARATION 2018: review of the programme budget content by the Ministry of Health 2020: complete review of the programme budget content planned for all the Ministries 13Process of transItIon to the Programme budget XIII (1) Policy document for the implementation of a Programme Budget in Burkina Faso, June 2010 (adopted by the Council of Ministers in June 2010); (2) “Programme budget implementation strategy” (approved by the government programme budget in June 2011 and adopted by the Council of Ministers in February 2012) supported by an action plan; (3) two methodology guides (a) to prepare the programme budget and (b) to monitor/evaluate the process in the ministries (adopted by the Council of Ministers in 2010 and 2011 respectively); (3) design of several mock-ups/outline for the ministerial “programme budget” document. XIV Order No. 2009-477/MEF/CAB of 29 December 2009 on the setting-up, roles, composition and running of the Steering committee for the government programme budget and Order No. 2009-484/MEF/CAB of 29 December 2009 on the Unit to set up the government programme budget. XV Their aims were to provide guidance, to stimulate and supervise the process and finally, to lead the work to be performed on incorporating the WAEMU directives into the finance laws. The Steering Committee for the government programme budget and the Technical secretariat of the Steering Committee for the government programme budget were established by decree in September 2010. XVI Their roles were (i) to work with the Ministry of Finance to contribute to the drafting or re-reading/transposition of the sector policy into a programme; (ii) to work with the Ministry of Finance to lead the process of drafting and monitoring the implementation of their ministry or institution’s programme budget and (iii) to participate in the implementation of any activity contributing to the drafting of the government’s programme budget. XVII The Integrated Expenditure System (CID) has been adjusted to the programme approach. The budget planning module for the information system was therefore deployed to ensure the 2017 draft budget could be prepared, and that the system could include all the tables using the programme approach and in accordance with the LOLF. Technical guidance: production and gradual revision of standards and tools (guidance document for the implementation of the 2010 programme budget), programme- budget implementation strategy (2011), methodology guides (2010 and 2011),XIII outline, work on dividing public policies into budgetary programmes (2010-2011), setting out annual performance plans (from 2011 onwards), guide for programme-budget execution (2017) Governance: setting up governance of the reform involving finance and the sectors (budget planning reform committee (2008), steering committee for the implementation of the programme budget (from 2009)XIV with implementation teams in each ministryXV and the creation of ministerial technical units for the programme budgetXVI) Adapting the management tools: adapting financial information systems to the new approach (review of the Integrated Expenditure System – CID)XVII Capacity building: producing a capacity-building plan for stakeholders, including in the sectors (2013), with the exception of programme officers (from the Ministry of Health) appointed after the training. Capacity building activities targeted at the financial responsible officers, and not the operational arm of the reform (e.g., budgetary programme directors). Legal framework: Suitable legal and regulatory framework, including the transposition of WAEMU directives (2013-2016) Adoption of a presidential circular in 2016 for official transition to the programme budget in all ministries. Box 1: Key factors for programme budget institutionalization in Burkina Faso 14 BUDGETING IN HEALTH 2.2 THE MINISTRY OF HEALTH’S TRANSITION TO A PROGRAMME BUDGET: ALIGNMENT WITH NATIONAL HEALTH STRATEGIES Historically, up to and including 2016, the Ministry of Health’s budget was an input or line budget. The budget was presented by type of expenditure, essentially based on four main categories (heading) and then broken down by economic classification (article, section, paragraphe) (Table 6). The budget was very detailed (up to paragraph level). For example, the budget was presented and reported to item level, i.e. for health, “fuel”, “office supplies” and “maintenance products” came under “operating expenditure” (Heading 3) (Table 6). From a sector point of view, this structure had several disadvantages: 1) expenditure was broken down into categories that were unrelated to the sector’s objectives and activities; 2) there was a lack of flexibility when reallocating between different itemsXVIII; 3) the reporting, although very detailed and burdensome, was limited and did not provide information on the sector’s actual performance. The Ministry of Health, a pilot ministry since 1998, has gradually worked on the transition to a programme budget. After a decade of trials and adjustments between 1998 and 2009, in 2010 the line budget was transposed to a programme budget. According to those in charge of the Department of studies and planning (now the Directorate general of XVIII The absence of flexibility belongs more to an expenditure management issue than a purely budget formulation and presentation challenge. However, since expenditure management is often aligned on budget formulation, budgets that are formulated by inputs are generally associated with lack of flexibility in the use of resources. sector studies and statistics), the Ministry sees this as the main advantage of “increased alignment between allocations and sector priorities.” The Ministry’s initial proposal in 2010 was built around 5 programmes and 24 actions, aligned with the strategic focus of the PNDS 2011-2020 (developed in 2010) and its 24 focus areas. Following discussions with the Ministry of Finance, a consensus finally emerged around a smaller group of three programmes: 1) access to services; 2) health services provision; 3) oversight and 24 actions. Future budgets pilots up to 2016 will be developed on this basis and then formalized from 2017 with some marginal modifications to the number and drafting of the actions (26 in 2017, 21 in 2018) and activities. When the 2011 programme budget was developed, it appears that a special effort was made to ensure consistency between the budget formulation and the National Health Development Plan, to pave the way for greater alignment between the expenditure and the sector’s needs. It is possible to map to map PNDS’s strategic objectives and budgetary programmes and identify obvious pathways (Figure 2). In the years following 2011, the same model was used to prepare the Ministry of Health’s budgetary programmes. The same formulation was used in the budgets from 2013 to 2016. During the review of the PNDS 2016-2020 (second phase), it was decided to align this Plan’s new strategic objectives on the presentation of the three budgetary programmes which now mirror one another (Figure 2). Since 2018, the budgetary programmes have needed to be redefined to bring them more in 15Process of transItIon to the Programme budget line with the sector’s vision championed by the Minister who took up the post in February 2017. Responding to the wish to have “a national health system that values prevention and makes the community-based approach to primary health care the foundation of Burkina Faso’s move towards universal health coverage”XIX, the new intended budgetary formulation is the following: 1) a national public health programme (covering prevention, promotion and health security); 2) a national programme of health care provision (and access to health products) that targets curative care; 3) a national programme of governance of the health system. However, this formulation has XIX Presentation by Prof. Nicolas Méda, Minister of Health: Vision, reorganization, priorities and response strategies, 2018, not been adopted for the official 2018 budget, and it is expected that the formal review will not take place before 2020 when the Ministry of Finance has scheduled a review of all budgetary programmes (Table 7). Expecting the official revision, for the project of finance law 2019, the ministry proposed the following formulation: 1) Access/Purchase of health care; 2) Provision of services/ public health; 3) Governance/Stewardship. This transitional approach was chosen in order to not overthrow the delivery of the operationnal content – which is identical to the 2018 budget. However, this creates an important confusion between the name and the outputs of the programmes. For example, under the programme «Provision of services/ public health», most actions are a matter of Table 6: Extract of the structure of the line budget, Ministry of Health (before 2017) Heading Chapter Article, section, paragraph Heading 3. Operating expenses Cabinet/General Secretariat/Departments Regional health directorates Health districts* Purchase of goods and services (article) – supplies (section) . fuel, office supplies, maintenance products, etc. (paragraph) . vaccines, specific supplies – expenditure on care/maintenance . building, vehicle, etc. – service provision . security costs, etc. . gas – others . meetings, travel, etc. . food, medicines, reagents, travel Heading 4. Current transfer expenditure Public establishments: university/regional hospitals National Centres Programmes/specific activities (diseases, free of charge/subsidies, national immunization days (NID), contributions to organizations, etc.) Interns/specialist doctors Operating Grants – subsidies to public institutions . salary, equipment, materials, medical care (public establishments, university/regional hospitals) – grants to beneficiary categories . support for activities (programme, specific actions) Other current transfers . contribution to organizations . internal allowances/bursaries Note: Health district: functioning of the district core team and provisions for medical centres with a surgical unit. Source: Budget 2016. 16 BUDGETING IN HEALTH provision (former name of this programme). To solve this problem, the Ministry of Health committed to work again on the content of programmes between 2019 and 2020, in order to propose a more coherent framework in 2020-2021 during the official revision. 2.3 CHANGING ROLE OF STAKEHOLDERS IN THE REFORM The Ministry of Finance managed the reform process with support from the International Monetary Fund (IMF). The transition to a programme budget was part of a deeper reform of modernizing public finance, mainly affecting the finance sector. The pressure from WAEMU with a 2017 deadline to introduce programme budgets in the subregion encouraged major investment, STRATEGIC GOALS OF THE PNDS 2011 BUDGETARY PROGRAMMES FOR HEALTH 2011-2018 STRATEGIC GOALS OF THE PNDS 2016 Figure 2: Mapping of 2011 PNDS objectives, 2011-2018 Ministry of Health budgetary programmes and 2016 PNDS objectives Increasing health financing and improving the affordability of health services Promoting health research Improving the management of the health information system Developing infrastructure, equipment and health products Promoting health and the fight against disease Developing human resources for health Improving health service delivery Developing leadership and governance in the health sector Access to health services Health service delivery Oversight and support for Ministry services Access to health services Health service delivery Oversight and support for Ministry services 17Process of transItIon to the Programme budget which was a reason for the heads of state to push the reform through. Soon, from 1998, by making sectors such as health or education pilot ministries for the reform, a dialogue was established between the finance and other sectors. The issue of alignment between the budget and the PNDS, which was key for the Ministry of Health, underlay the Ministry of Health’s increased engagement, which began in 2010. This was a critical issue from a sector planning perspective and was consolidated in 2010 with the development of the PNDS 2011-2020. The dialogue was framed by various joint committees, led by finance, but with the participation of players in the health sector (mainly the Department of studies and planning). The first to be involved in the Ministry of Health were individuals working on strategic planning. In 2010 (and so until 2016), the Department of studies and planning (now the Directorate general of sector studies and statistics) was responsible for formulating the consolidated budget around three programmes. The personal comitment of the director of the Directorate general of sector studies and statistics, who was convinced of the interest of such a reform for the sector, has been an important factor for the progress of this process. The technical directorates and lower administrative levels (e.g. for the sector: districts, health facilities, etc.) however, seemed less involved. It appears that a bottom-up approach was not followed, explained by the fact that the PNDS, the framework document developed in consultation with all the stakeholders in the sector, formed the basis for formulating budgetary programmes. A change of organization and of the organization chart of the Ministry of Health in June 2018 allowed the emergence of two large general directorates namely in charge of the two first budgetary programmes (Table 7). Aligning the Ministry’s new organization with the programmes in 2018XX appears to be a positive factor in successful institutionalization. The Directorate General for Public Health is expected to take the lead on the “new” public health budgetary programme (formerly, “access to health services”), while the Directorate General for Health Care and Health Products will manage XX Ministry of Health’s organization chart, May 2018 Table 7: Alignment between the new budgetary programmes and the Ministry of Health’s reorganization (2018) Formulation of budgetary programmes (until 2018) New formulation of budgetary programmes (as formulated by Ministry of Health); post-2018 Allocation to new Directorates (from 2018 onwards) Access to health services Public health Directorate General for Public Health Delivery of health services Supply and purchasing of health care Directorate General for Health Care and Health Products Oversight Oversight and governance Directorate General for Sector Studies and Statistics Source: Authors 18 BUDGETING IN HEALTH the new national care supply programme (formerly, “delivery of health services”). The Directorate General for Sector Studies and Statistics – DGESS – will remain the lead for the third transverse programme on system governance (Table 7). When the departments in charge of the budgetary programmes in the Ministry take over the role, they will require capacity building and support in two principal areas. First of all, as required by the Minister, the newly appointed teams will have to be equipped to oversee the review of the content and outlines of the budgetary programmes (planning, prioritization, coordination both horizontally and with the levels below, definition of the performance monitoring framework). These teams will also have to be trained in the operational and financial management of a budgetary programme, from planning, spending, to financial monitoring and reporting on performance. With the appointment of programme managers in October 2017, it is expected that they become more involved both in the formulation of future programme budgets and in their implementation/execution (from 2021XXI onwards). In fact, Article 67 of LOLF states that the authorization (“engagement”) may be delegated to the programme manager who therefore “authorizes” the expenditure, with financial managers being part of each programme’s management team. The programme manager will be answerable for achieving the results. The role of the Finance and Administration Department – DAF will therefore be modified and limited to monitoring/financial reporting of the Department’s overall expenditure. The DAF is expected to be replaced by financial officers integrated in each programme unit. XXI Initially planned for 2019, the scale plan was rescheduled, in June 2018, to 2021. 19structure and content of the mInIstry of health’s budgetary Programmes Built around three major programmes, the structure of Burkina Faso’s Ministry of Health programme budget is simple. It complies with legal requirements and is aligned with the goals of the PNDS 2011- 2020. However, a more in-depth analysis reveals some weaknesses and a need to review the drafting and shaping of certain actions and activities to improve their relevance and alignment with the programme’s goals. While the programme budget has had an impact on the sector as a whole, it has specifically changed the position of specific interventions such as immunization or the fight against major epidemics, which are now part of broader budgetary programmes. 3.1 STRUCTURE OF THE MINISTRY OF HEALTH’S PROGRAMME BUDGET The Ministry of Health’s programme budget, adopted in 2017 and 2018, complies with legal requirements and follows a programme/action/activity model, in line with international recommendations (Figure 3). The “programme” level includes a public policy, a sector priority to which a goal is attached (e.g. access to quality health services), while the “action” is generally associated with a set of measures (e.g. strengthening the infrastructure) implemented to achieve the programme’s goal. In the Ministry of Health’s programme budget, an “activity” relates to more specific projects that have clearly identified costs (e.g. setting up a fund, purchasing vaccines). The number of programmes, actions and activities in the sector complies with legal requirements (maximum 7 programmes, 10 actions per programme and 40 activities). In 2018, the Ministry of Health’s first two programmes comprise six actions each, the transverse oversight programme have nine. Each action is then broken down into activities. Each action generally comprises a variable number of activities (see Appendix 2 for a detailed list of actions and activities). The access programme includes 44 activities (excluding salaries); the second, 20 activities (excluding salaries), and the last programme has 39. From 2018 onwards, the health MTEF has followed the same format as the annual budget and is structured, according to the budgetary programmes named before, besides the strategic orientations of the PNDS. This is a considerable step towards better alignment and it will make it easier to anticipate the annual budgets for each programme. 3. STRUCTURE AND CONTENT OF THE MINISTRY OF HEALTH’S BUDGETARY PROGRAMMES 20 BUDGETING IN HEALTH However, the MTEF’s usefulness is in question as the budgets have now been approved for three years (Box 2). 3.2 ANALYSIS OF THE CONTENT OF THE MINISTRY OF HEALTH’S BUDGETARY PROGRAMMES The Ministry of Health’s first two programmes meet the sector’s main and key objectives in the PNDS, namely (i) improving people’s access to quality health services (access programme); (ii) reducing morbidity and mortality through better prevention, effective care and a change of behaviour (benefits programme). Even if formulations appear to be at different levels – one at output and the other at outcome level, the content in both programmes relate to an overall system logic. By incorporating disease- specific work into broader programmes, this budget formulation paves the way for a more coordinated approach in the system. The “service delivery” programme also has an advantage from a sector point of view in facilitating the establishment of a strategic purchasing function. Different actions or activities relate to a purchasing function without links being explicitly established: action 2 relates to funds for districts, health PROGRAMME 1 ACTION 1 ACTIVITY 1 ACTIVITY 2 ACTIVITY 3 ACTIVITY 4 ACTIVITY 5 ACTION 2 ACTION 3 ACTION 4 ACTION 5 ACTION 6 Figure 3: Structure of the Ministry of Health’s budgetary programmes in Burkina Faso Source: 2016 Budget 21structure and content of the mInIstry of health’s budgetary Programmes facilities, specific dedicated funds; action 3 to the provision of care; action 5 to funds dedicated to health promotion. In light of the health financing reform, the payment systems for these different services have yet to be established/adapted. However, some imprecisions, incoherences and overlaps were detected. Although the division between the two programmes suggests that the first programme covers prevention and the second encompasses curative care following a functional approach, a more in-depth analysis of each programme’s outlines reveals that this distinction is not as clear with respect to actions. The “access” programme mainly includes actions that pertain to strengthening the health care offer (design, staff training, equipment, health products). The “services” programme, which could be thought of as related to curative services, actually includes several preventive actions (disaster health management, health promotion, community participation). In the next programme review, it is important to clarify the outlines for each programme and align their formulation with the content. An in-depth analysis for each action also suggests certain weaknesses at this level and appears to indicate a need to review their definition and formulation to improve their relevance. The programmes contain very different types of action. In the “services” programme, some refer to results (e.g. reduced endemic/epidemic disease morbidity and mortality); many others seem to refer more to activities (e.g. disaster health management). In 2001, the overall MTEF, the Medium-Term Budget Framework (MTBF), was introduced. It was structured by type of expenditure following the model used at the time in the annual budget. The first MTEF for the health sector was elaborated in 2005, following the strategic orientations of the National Health Development Plan (2001-2010). From 2011-2012, the health MTEF was formulated according to the PNDS 2011-2020’s eight strategic objectives and based on three scenarios, on the basis of Marginal Budgeting for Bottlenecks (MBB) cost estimates. The same still applies to the MTEF 2017-2020. It is considered an advocacy tool to mobilize more domestic but also external resources (external aid), by demonstrating the gap in funding between what is needed to achieve the strategic goals and the budgets allocated for the sector by the overall MTEF. Since it was decided to adopt a three-year programmes budget, the MTEF has ceased to be useful. The predictability that made the tool valuable in the annual state and sector budgets has become less important. The budget is now prepared for three years and adjusted each year according to macroeconomic forecasts and priorities. However, the health sector appears to want to retain the health MTEF in the future viewing it as a useful tool for its advocacy to mobilize resources, particularly external ones. From 2018 (MTEF 2018-2021), the structure of the health MTEF is expected to change and align with the structure of the Ministry of Health’s three budgetary programmes, on top of a PNDS divided into strategic goals and type of expenditure (based on three different scenarios). Box 2: Changes in the aggregate and sector MTEF structure in Burkina Faso 22 BUDGETING IN HEALTH In the “access” programme, actions refer more to the linchpins or inputs in a health system (personnel, infrastructure, equipment, etc.) (Table 8). XXII Some actions have been canceled between 2017 and 2018, like the action 05506. The action 05705, not present in 2017, has been reintroduced in 2018. The “activities” level appears to cover an even more diverse group of projects, which creates problems with the formulation, or means they are disconnected from the action they belong to. While some activities are well- defined and consistent with the action and the programme, others appear reductive and/ or not aligned with the programme’s goal. For Table 8: Ministry of Health’s programme budget’s programmes and actions (2018)* Programmes and actions 055 Access to health services 05501 Training of health personnel 05502 Constructing/rehabilitating health facilities 05503 Purchase and maintenance of sanitary equipment 05504 Improving the availability of quality health products 05505 Promoting systems to divide risks in the area of healthXXII 05507 Promoting traditional medicine and pharmacopoeia 056 Health service delivery 05601 Community participation 05602 Reducing morbidity and mortality associated with endemic/epidemic diseases 05603 Quality mother and child health services 05604 Disaster health management 05605 Health promotion 05606 Health product quality assurance 057 Oversight and support of Ministry of Health services 05701 Oversight, coordination and intersector collaboration of Ministry of Health actions 05702 Increase in health sector financing 05703 Management of financial and material resources 05704 Management of human resources 05705 Planning, monitoring and evaluation 05706 Building/rehabilitating and equipping administrative and educational infrastructure 05708 Health information 05709 Promoting health research 05710 Communication Source: Budget – expenditure, Ministry of Health, 2018 (CID). * Note: for the project of the finance law 2019, the proposed formulation is: 055 access to services/public health; 056 provision of health services/purchase; 057 oversight and support of services of the Ministry of Health/governance of health system 23structure and content of the mInIstry of health’s budgetary Programmes example, with respect to promoting health, the main action, in 2017, is to “ensure the central and other authorities are working”, which does not appear to be directly focused on achieving the expected result (“improve hygiene, sanitation and behaviours conducive to good health”). Another example relates to the oversight programme; the “increased funding” action is linked to the programme budget formulation activity, which is certainly insufficient to increase funding, even though it can contribute towards advocacy for more resources for the sector. 3.3 IMPLICATIONS OF THE REFORM FOR SPECIFIC HEALTH PROJECTS (IMMUNIZATION, HIV/AIDS, MALARIA, TUBERCULOSIS) The transition to the programme budget affected the budget item to which expenditure on disease-specific projects was charged, an aspect little known to national or international partners (e.g. Global Fund, GAVI) in these sectors. Their position in the budget has changed and it is important to map and monitor this development. At this stage, interventions seem to be in the correct place (“activities”) and corresponding to a rationale that is consistent with the PNDS. While a more in-depth understanding of the consequences of this transition on funding for diseases is still a little premature, at this stage it does not appear to have affected the level of funding for each disease/project.XXIII With regard to immunization, before the reform, budgetary provisions for immunization XXIII Rising for immunization, for example: from 2.2 billion CFA francs in 2017 to 3.2 billion CFA francs in 2018. came primarily under two main headings: purchasing vaccines and consumables and support for national immunization days (NID). Since the transition to a programme budget, this expenditure is now divided between the two budgetary programmes (access and services). Both operations can be found under “activities”.XXIV The purchase of vaccines is now charged as an activity in the “Access to services” programme, under the “Improving the availability of quality health products” action. As for the contribution to the financing of NIDs, this activity is included in the “Health Services Delivery” programme, under the “Quality health services for mother and child health” action (Table 9). The situation is different for each of the three major epidemics (HIV/AIDS, tuberculosis and malaria). While some provisionsXXV are planned by the Ministry of Health, HIV/AIDS-related projects are mainly funded by the National multisector programme to combat HIV/ AIDS and sexually-transmitted infections, a programme of the National council to combat HIV/AIDS and STDs placed under the auspices of the Presidency. Before the 2017 budget reform, spending on national resources was divided in the Presidency section into operating expenditure, a grant for the AIDS Solidarity Fund, and an entry under investment for the “project to XXIV Although the budget item to which it was charged is different, the nature of the expenditure does not change (e.g. transfers for national campaigns). XXV “Ensure the functioning of the HIV/AIDS/STD sector” provision/activity, “Health service delivery” programme and “Ensure the effective functioning of the Ministerial Committee to Combat AIDS/STD (CMLS-STD)” provision/ activity, “piloting and support” programme. 24 BUDGETING IN HEALTH support the implementation of the Strategic Framework for the fight against AIDS”. From 2017 onwards, the provisions were grouped under a “Fight against HIV, AIDS and STDs” programme divided into three actions: 1) Preventing the transmission of HIV/AIDS and STDs; 2) Care, treatment, support and protection of those who are affected; and 3) Governance, funding of the response and strategic information management” (Table 9). The Ministry of Health is responsible for a number of activities that respond to the aforementioned three actions, either on its own (e.g. promoting sexual and reproductive health) or alongside other ministries (e.g. promoting safer behaviour). Although the Ministry of Health is responsible for the implementation of some activities, the budgetary allocation remains with the Presidency. The fight against tuberculosis is mainly financed external by partners (partly off- budget). With respect to state budget provisions through the Ministry of Health, the shift to a programme budget format required including funding dedicated to the prevention and fight against this disease in the “benefits” programme. The provisions were previously essentially a contribution to the operation of the National and regional tuberculosis control centre and to the National reference laboratory for tuberculosis, as well as a non-itemized provision to run the National tuberculosis control programme (under the Department of Health operating subsidy). Since the transition to the programme budget, this same earmarked funding has been charged to the “benefits” programme under the “reducing endemic/epidemic morbidity and mortality” action, and the “support for the national tuberculosis control centre” activity. Other unrestricted funding also covers actions/activities related to the fight against tuberculosis including: the staff, the running of diagnostic and treatment centres, the monitoring and dispensing of treatment devolved to the health and welfare centres, as well as the payment of allowances to CBHWs who perform screening activities/provide support with treatment compliance. With regard to malaria, domestic funding is historically associated with two main types of activities: 1) a provision to run the National malaria research and training centre, which is now part of the “Steering and support for Table 9: Allocation of pre-reform and post-reform immunization expenditure Pre-reform (before 2017) Post-reform (2017 & 2018) Heading Programme Action Activity Heading 3. Operating expenses Chap. 65137. Department of prevention through immunization 621 62. Medical immunization products 621 69. Other specific supplies 055. Access to health services 05504. Improved availability of quality health products 0550401. Purchase vaccines and consumables Heading 4. Current transfers Chap. 61141. National Immunization Days 056. Health service delivery 05603. Quality health services for mother and child health 0560303. Organize national immunization days Source: Budgets 2016, 2017, 2018 (CID)18 25structure and content of the mInIstry of health’s budgetary Programmes services” programme under the “Promotion of health research” action; 2) funding for preventive or curative activities related to the free programme (Table 11). The free health care programme for children under 5 years of age and for pregnant (preventive and curative) and postpartum (curative) women, now included in the “access” programme, covers much of the funding of malaria-related activities owing to malaria’s importance both in preventive and curative activities for children and pregnant women. From 2017, a specific “Ensuring the implementation of the free health care strategy” activity was included in the “Promotion of mechanisms for sharing health risks” action in the “Access to health services” programme. A second activity in the same programme that refers to the “Improving the availability of quality health products” action, was however maintained to cover the purchase of malaria drugs, among others. These two budget “items” cover the authorities’ contribution to subsidizing “free” treatment in the fight against malaria. Table 10: Actions and activities posted under the Presidency’s “Fight against HIV, AIDS and STDs” budget plan Actions Activities Action 1: Preventing the transmission of HIV/AIDS and STDs Promoting safer behaviour through Information Education Communication/ Behaviour Change Communication and Sexual and Reproductive Health; promoting male and female condom use; promoting sexual and reproductive health and screening advice; eliminating mother-to-child transmission of HIV (+ projects financed externally) Action 2: Care, treatment, support and protection of infected and affected individuals Strengthen biological, medical-technical and clinical services; strengthen the drug supply system, including ARVs, reagents, consumables and equipment; increase the involvement of associations and communities in the continuum of care for people infected and affected by HIV; improve the financial support for PLHIV, people who are affected and specific groups in all sectors Action 3: Governance, financing the response and strategic information management Ensure the leadership is coordinated and maintained; strengthen the organizational and institutional capacities of facilities; ensure internal and external resources are mobilized; conduct epidemiological, sector behaviour and impact studies; improve the organization of the national monitoring and evaluation system; document and disseminate best practice in the fight against HIV and STDs Source: Budget – expenditure, Faso Presidency, 2018 (CID). Table 11: Budget allocation of malaria prevention and management expenditure in the programme budget (post-reform) Programmes Actions Activity Steering Promoting Health Research Ensuring the functioning of the National malaria research and training centre Access Promoting risk-sharing mechanisms Ensuring the implementation of the free health care strategy Improving the availability of health products Purchasing malaria drugs Source: 2017 & 2018 Budget 26 BUDGETING IN HEALTH The sector’s transition to the programme budget in 2017 and 2018 brought a certain degree of flexibility in public health expenditure. The adjustments and reallocations between 2017 and 2018, and between and within budgetary programmes in the same year, are all signs of more flexible budget programming. Expenditure practices are also becoming more flexible and are shifting towards spending that is more responsive to the sector’s changing needs. If Burkina Faso adjusts the programme budget performance monitoring framework, it will then have a very useful tool that provides information on programmatic and financial performance of the sector and which would inform future allocation decisions between and within programmes. 4.1 MOVING TOWARDS AN END TO ANNUAL DEFERRED BUDGETARY PROGRAMMES? The formulation of the budgetary programmes evolved between 2017 and 2018; adjustments in actions and activities made it possible to improve the programmes’ alignment with the items beneath them. For example, in 2018, the “functioning of central and regional directorates” activity was charged to the “oversight and support of services” programme, whereas in 2017 it had been included in the “health promotion” action of the “delivery of services” programme. The “functioning of health districts and university/ regional hospitals” activity was transferred from the “health promotion” to the “reducing endemic/epidemic morbidity and mortality” action in the “Services” programme. New activities were included, moving away from a budgeting approach that carries forward the same level of allocation for the same activities from one year to the next. A key point was added under “Reducing endemic/ epidemic morbidity and mortality”, which now includes support for districts, regional health facilities and tertiary entities (university/ regional hospitals). Also, the “Community- based health worker management” activity was added under “community participation” in 2018, whereas no activity had been recorded in 2017. Two activities were added to the management programme (“Payments to the health research support fund; Ensuring that the National institute of public health (INSP) is operational)”, while 2017 only provided for more targeted support for two local research facilities. In addition to the formulation, the allocations to the various programmes were reviewed each year. In 2017, the largest allocations were for the “access” programme (52% of the total Ministry of Health budget), while the “benefits” programme has the largest share of the budget in 2018 (47%). The “oversight” programme is relatively unchanged at 12% and 14% for 2017 and 2018 respectively (Figure 4). While the Ministry of Health’s global budget changed little from 2017 to 2018 (+2%), there were major variations between and within programmes and actions. The differences are 4. FIRST EFFECTS OF THE REFORM (2017-2018): PROGRESS AND CHALLENGES 27fIrst effects of the reform (2017-2018): Progress and challenges mainly due to a substantial transfer of staff costs from the “access” programme to the “benefits” programme (-76%/+83%), but a different allocation for certain activities can also be observed between 2017 and 2018. For instance, variations of more than 70% were seen in health promotion, service provision for mother and child and health product quality assurance (see details in Appendix 3). 4.2 TOWARDS MORE FLEXIBILITY IN SPENDING? A key innovation lies in the set up of more flexibility in expenditure and the «relaxing» of some ex ante controls to authorize expenditures. The commitment is now done on the basis of programme with a justification at the level of «section» (and not at the paragraph anymore). However, it is worth noting that in a certain way, the input-based logic is still present in the authorization process of expenditure, through the request of justification by section («rubrique»). Flexibility in expenditure is reflected in practice through varying levels of execution between and within programmes. Table 12 shows these varying levels of implementation between the two main programmes (115% implementation for the “access” programme and 66% for the services programme in 2017), while maintaining a relatively satisfactory overall level of implementation (93%). Apart 51,8% 35,8% 12,4% Budget 2017 37,6% 47,5% 14,9% Budget 2018 055 Access to health services 056 Health service delivery 057 Oversight and support Figure 4: Distribution of budget appropriations by programme in 2017 and 2018, Ministry of Health Source : Ministère de la Santé, 2017 et 2018 28 BUDGETING IN HEALTH from personnel, fungibility provides the flexibility for expenditure items within the same programme to vary up or down with no pre-set limit. The level of implementation of the actions within the programmes themselves varies significantly from 33% to 175%. While variations in the implementation levels of activities are probably due to the lack of stabilization in the activities, they are likely to be associated financial management that is more flexible than before and that is more responsive to the sector’s changing needs. Health personnel costs are charged to each of the Ministry of Health’s budgetary programmes.XXVI They therefore avoid the common pitfall of being registered and managed outside the programmes within a specific staff line or lines. The Ministry of Health’s budget therefore includes three “blocks” for remuneration (the “balance”), which are connected to the first action in each programme (with no specific relation to the content of the action) and could have the advantage of including a major cost factor (58% of expenditure within the “benefits” XXVI Personnel expenditure at tertiary level (university/regional hospital) is accounted for in transfers to these bodies and is therefore not included in the remuneration expenditure programme in 2018 for example) as part of a true model of programme efficiency. However, the implementation of staff costs differs significantly from the 2017 allocations, implying an unreliable estimate of needs. In the “access” programme, implementation is much higher than stated in the initial budget (190% of the revised provisions). For the “services” programme, only 25% were executed. In 2018, there will be a mass transfer of salaries to the “benefits” programme (twice the allocations of 2017), which will now cover 70% of salaries, while allocations in the “access” programme will be cut to one third. Since salaries remain the Ministry of the Economy, Finance and Development’s responsibility, in practice, dividing staff costs across the Ministry of Health’s three programmes therefore appears to be a rather artificial exercise. The entries are not in fact linked to the action they have been logged under. In the first programme, salaries appear under “training health staff” and in the second programme, under “community participation”. The expenditure relates to a retroactive entry in the monitoring of the expenditure because, even if it is charged to the health budget, there is limited room for manoeuvre for health to adjust the Table 12: Implementation of the health budgetary programmes (2017) Initial provision (thousands CFA francs) Revised provision (thousands CFA francs) Settlement (thousands CFA francs) Implementation (%) Access to health services 121,287,749 101,457,294 117,515,245 115.8% Provision of health services 71,585,283 70,051,757 46,313,277 66.1% Steering and support 23,193,257 24,210,695 19,069,684 78.8% Total 216,066,289 195,719,746 182,898,206 93.4% Source: CID, 2017 29fIrst effects of the reform (2017-2018): Progress and challenges payroll to meet each programme’s goals (see section 1.2). Until the Department has the capacity to incorporate staff management and remuneration more effectively into the programmes, it will be limited in its ability to move towards more strategic purchasing of services and hence more flexible and efficient spending. Table 13: Extract from the Ministry of Health programme budget’s Performance Monitoring (2018-2020) Strategic objectives Indicators Reference Targets Responsible directorate Unit Year Value 2018 2019 2020 Programme 056 Health service delivery Reduce morbidity and mortality for better prevention, effective treatment and a change in behaviour Maternal mortality rate RATIO 2016 341 243 243 243 DGESS Mortality rate for children under five RATIO 2016 ND 62,75 62,75 62,75 DGESS Action 05601 Community participation Promote community-based action in the area of health Number of NGOs who have a performance contract with the Ministry of Health NO. 2016 252 252 252 252 DGS Number of villages covered by the OBC-E NO. 2016 8000 8000 8000 8000 DGS Action 05602 Reducing morbidity and mortality related to endemic/epidemic diseases Promote community-based action in health1 New contacts per inhabitant and year in the primary health care facilities (CM and CSPS) NO. 2016 1,02 1,3 1,4 1,5 DGESS Bed occupancy rate in the hospitals % 2016 50,5 60 65 70 DGS Action 05603 Quality service offer for mother and child Improve mother and child health Rate of assisted deliveries % 2016 80,9 >=87 >=90 >=90 DGESS Rate of caesarean sections among assisted births % 2016 >=3.5 >=3.8 >=3.9 >=4 DGESS Immunisation rate of pentavalent vaccine among children % 2016 103 100 100 100 DGESS Action 05604 Disaster health management Improve disaster health management Coverage rate for disaster victims % 2016 NA 80 80 80 DGS Proportion of hospitals with a response plan <plan blanc> % 2016 100 100 100 100 DGS 1 The repetition of actions between 05602 and 05601 is provided in the original document. DGESS: Directorate general of sector studies and statistics DGS: Directorate general of health Source: Budget 201819 30 BUDGETING IN HEALTH 4.3 TOWARDS FINANCIAL ACCOUNTABILITY THAT IS OF BENEFIT TO THE SECTOR? The programme budget is combined with the implementation of a performance monitoring framework (PMF)21 that makes it possible to link changes in the sector’s performance to the resources that have been allocated, creating monitoring that had not previously existedXXVII. The PMF is defined according to the programme (and not by input) and aims to provide information on achieving the goal that has been set for each of the two programmes, namely “improving access to quality health services” and “reducing morbidity and mortality through improved prevention, effective treatment and changes in behaviour” (see section 3.2). The performance framework has the advantage of being at programme and action level. The programme manager is therefore expected to report to action level and not to a lower level (activities), therefore giving them some autonomy in the implementation of activities. They will not be judged on whether XXVII Performance monitoring under the PNDS does not link the achievement of the goals directly to the expenditure to achieve these same goals. or not an activity is complete, but on whether a particular result has been achieved for the sector, depending on the resources that have been allocated (Table 13). While the volume of performance data to be reported appears to be relatively moderate at this stage in comparison to international standards,XXVIII the performance framework would appear to require adjustment if it is to measure the achievement of the expected results. The indicators, which are currently aligned with the PNDS, do not follow a clear “logical framework” between results and inputs. If Burkina Faso adjusts the framework, it will then have a very useful tool to provide information on sector programmatic/ operational and financial performance and inform future decisions on allocations between and within programmes. If annual performance monitoring is used to influence future decisions on allocations in the sector, the programme budget and its performance framework will be able to make a significant contribution to the sector. XXVIII One sole outcome indicator is provided, and a maximum of three outcome indicators per action are suggested. 31summary of Progress, challenges and recommendatIons SUMMARY OF PROGRESS, CHALLENGES AND RECOMMENDATIONS Summary of progress and challenges in the implementation of the health programme budget in Burkina Faso Progress Challenges Budget planning Aligning budget formulation with PNDS (2011-2020) priorities Need to update the outlines and content of budgetary programmes in light of new policy directions for the sector Year-to-year adjustments between and within programmes Usefulness of the MTEF given that the budget is defined for three years Harmonizing departmental organization and budgetary programmes to facilitate implementation and accountability Delay in appointing managers following the reorganization of the Ministry of Health, which could not affect the budget planning before 2019 “Responsibility chain” to be redefined following the ministry reorganization Implementing expenditure Financial management tools adjusted to programme budgeting Non effective transferring of expenditure authorizing to programme managers Effective implementation of the principle of decentralized authorizing at the benefit of health Minister Artificially including staff remuneration with programme formulation Effective implementation of the fungibility principle at programme level Fungibility authorised/justified on the basis of inputs Performance monitoring and accountability Annual performance monitoring at programme and action level Relevance and consistency of performance framework to be improved Technical capacity and ownership Understanding, ownership and leadership in the design of programme budget by ministry of Health Lack of ownership by newly appointed programme managers Strong DAF teams formed “Operational” teams not complete and not trained to manage effectively budgetary programmes 32 BUDGETING IN HEALTH RECOMMENDATIONS The following roadmap was defined and reviewed and refined by participants of the MOH/WHO seminar on programme budget in health, organized in Ouagadougou on 11-12 July 2018 Formulation of budgetary programmes in health: Reformulate the name, the content, and the outline of the budgetary programmes according to new orientations of the sector; Use the results of the annual reports on performance to inform the budgetary allocations of the following year; Ensure coherence in the performance monitoring framework with the new budgetary programmes; Clarify the purpose of the sectoral MTEF (information and advocay), the three- yearly budget in front of the primary tool for budgetary programming. Implementation and monitoring of the budgetary reform in health: Take part and use the results reform review to integrate the lessons for a rapid implementation of the reform in 2020- 2021; Formulate and make more operational the communication and coordination mechanisms between and within the budgetary programmes teams, at a financial and operational level; Prepare the effective transition of the financial management of programmes, including the integration of financially in charge people within the programmes; coordinate the implementation of the budget reform with the reform of health financing, specifically related to the universal health insurance scheme and the other measures concurring to a more strategic purchasing of health services; ensure coherence between the institutionalizing of budget reform with the implementation of decentralization(in particular pending transfers of skills to the regions); make progress with the Ministry of Finance and the Civil Service on allocating the remuneration of health personnel at the programme level Implementation of the teams and capacity building: Finalize the assignments, organization and the working of the different entities and the new created directorates according to the organization chart of 2018 of the Ministry of Health; Strengthen programme managers’ capacities to prepare and manage the budgetary programmes by giving them a specific training; Make the teams of the programme managers operationnal, by including trained financial managers in each programme. 33summary of Progress, challenges and recommendatIons BIBLIOGRAPHY 1. Barroy H, Dale E, Sparkes S, Kutzin J. Budget matters for health: key formulation and classification issues, Policy brief N°4, World Health Organization, 2018 (http://apps.who. int/iris/bitstream/handle/10665/273000/WHO-HIS-HGF-PolicyBrief-18.1-eng.pdf?ua=1) 2. World Health Organisation. Budgeting in health, Genève : Organisation mondiale de la Santé (http://www.who.int/health_financing/topics/budgeting-in-health/en/) 3. Union économique et monétaire ouest-africaine. Guide didactique de la Directive n°06/2009/ CM/UEMOA portant lois de finances au sein de l’UEMOA. Dakar : UEMOA, 2009 (http:// www.droit-afrique.com/upload/doc/uemoa/UEMOA-Directive-2009-06-lois-de-finances. pdf, consulté le 15 mai 2018) 4. Union économique et monétaire ouest-africaine. Rapport de mise en oeuvre du cadre harmonisé des finances publiques, 2e réunion de l’Observatoire des Finances Publiques. UEMOA, Lomé, 7-11 novembre 2016. 5. Secrétariat général du gouvernement et du Conseil des ministres. www.legiburkina.bf 6. Lawson A., Chiche M., Ouedraogo I. Évaluation de la réforme de la gestion des finances publiques au Burkina Faso 2001–2010, Danida, Rapport d’étude de cas pays – version finale. Danish International Development Assistance (Danida), Swedish International Development Cooperation Agency (Sida). Stockholm, 2012 (https://www.oecd.org/fr/pays/burkinafaso/ burkina_francais.pdf, consulté le 15 mai 2018) 7. Ministère de l’Économie et des Finances. Politique sectorielle 2011-2020 de l’économie et des finances – POSEF 2001-2010. Ouagadougou, 2011. (http://www.sips.gov.bf/img_tmp_ fichiers/MEF-PS-1.pdf, consulté le 15 mai 2018) 8. Ministère de la Santé. Stratégie nationale de financement de la santé pour la couverture santé universelle, 2017-2030. Ouagadougou. Octobre 2017 9. Ministère de la santé. Comptes nationaux de la santé, 2015 10. Kelley A.et al. Une vue d’hélicoptère : cartographie des régimes de financement de la santé dans 12 pays d’Afrique Francophone. Communauté de Pratique Accès financier aux Services de Santé et Communauté de Pratique Financement Basé sur la Performance, 2014 (http://docplayer.fr/amp/76977257-Une-vue-d-helicoptere-cartographie-des-regimes- definancement-de-la-sante-dans-12-pays-d-afrique-francophone.html, consulté le 15 mai 2018) 34 BUDGETING IN HEALTH 11. ASMADE. Inventaire des mutuelles sociales dans la perspective de l’assurance maladie universelle au Burkina Faso. Ouagadougou, 2011 (http://ongasmade.org/new/images/PDF/ ouvrages/INVENTAIREDESMUTUELLESSOCIALES2011VF.pdf, consulté le 15 mai 2018) 12. Étude sur le système mixte de modalités d’achat et de paiement des services de santé : Cas du Burkina Faso. Genève, Organisation mondiale de la santé, 2017. 13. Code général des collectivités territoriales 2004 14. Décret 2009-109/PRES/PM/MFPRE/MATD/MEF du 3 mars 2009 portant transfert des compétences et ressources de l’État aux communes dans le domaine de la santé 15. Décret 2014/920/PM/PATD/MDS/MEF/MFPTSS du 10 octobre 2014 portant transfert des compétences et ressources de l’État aux régions dans le domaine de la santé 16. Circulaire budgétaire n°97-054/PRES du 26 mai 1997 pour la préparation de la loi de finances-gestion 1998 17. Décret N° 2016-600 sur la nomenclature budgétaire 18. Écran d’engagement du Circuit informatisé de la dépense (CID) à la date du 14 février 2018 19. Ministère de la Santé. Cadre de performance des programmes budgétaires du Ministère de la santé, 2018-2020. 35bIblIograPhy LIST OF OFFICIAL DOCUMENTS REVIEWED Public financial management and programme budget documents DANIDA, Evaluation of Public Financial Management Reform in Burkina Faso 2001-2010, Country case study report – Final version, June 2012 Ministry of the Economy and Finance, Detailed report of the medium-term fiscal framework 2016-2018, April 2015 Ministry of the Economy and Finance, Economic and financial sector policy 2011-2020, April 2011 Ministry of the Economy and Finance, Guidance document for the implementation of the programme budget in Burkina Faso, June 2010 Ministry of the Economy and Finance, Methodology guide for drafting the government’s programme budget, Ministry of the Economy, Finance and Development, Forecast of overall expenditure by type 2018-2020 Ministry of the Economy, Finance and Development, Multiyear budget and economic planning document 2018-2020, April 2017 Ministry of the Economy, Finance and Development, Proposed staff costs 2017-2019, Baseline scenario, Ministry of the Economy, Finance and Development, Programme budget implementation guide, Public expenditure component, April 2017 Ministry of Health, Medium-Term Expenditure Framework 2016-2018, 12th edition, December 2015 Ministry of Health, Medium-Term Expenditure Framework 2017-2019, 13th edition, December 2016 Ministry of Health, Medium-Term Expenditure Framework 2018-2020, 14th edition, December 2017 Ministry of Health, Ministry of Health programme budget 2013-2015, September 2012 36 BUDGETING IN HEALTH Ministry of Health, Ministry of Health programme budget 2015-2017, Final Version, September 2014 Ministry of Health, Ministry of Health programme budget 2016-2018, draft, June 2015 Ministry of Health, Ministry of Health programme budget 2017-2019, October 2016 Ministry of Health, Ministry of Health programme budget 2018-2020 Ministry of Health, Settlement bond No. 2017-2140-6 of 23 October 2017 Public financial management and statistics support programme, Mid-term evaluation of Economic and financial sector policy 2011-2020, 2015 West African Economic and Monetary Union, Press statement of the ordinary session of the Council of Ministers of the Union, Dakar, 31 March 2017 Health-specific documents National assembly, Summary report of the parliamentary inquiry into the health system in Burkina Faso 2006-2016, July 2017 Ministry of Health, Classification of National Health Development Plan 2011-2020 activities (Phase II), May 2017 Ministry of Health, Draft national health sector policy, August 2017 Ministry of Health, Guide for drawing up annual action plans for central and technical directorates, December 2017 Ministry of Health, Health sector policy support project (PAPS/UE-Lot2), Draft study report on the mission, role and functioning of the health district in the light of current reforms, June 2017 Ministry of Health, Joint assessment of the National Health Development Plan in Burkina Faso 2011-2020, Final assessment report, September 2016 Ministry of Public Service, Labour and Social Welfare, Classification and tariffs of professional health procedures in public health facilities and hospital establishments in Burkina Faso, draft report, July 2017 Ministry of Health, Mid-term evaluation report of the PNDS 2011-2020 Burkina Faso, Ministry of Health, Mid-2017 Performance sector report, National Plan for Economic and Social Development, Health planning sector, August 2017 37bIblIograPhy Ministry of Health, Monitoring and Evaluation Plan of the Malaria Strategic Plan 2016-2020, January 2017 Ministry of Health, National Health Development Plan 2011-2020, 2011 Ministry of Health, National Health Development Plan PNDS 2011-2020, Phase 2016-2020, December 2016 Ministry of Health, National health financing strategy for universal health coverage 2017-2030, October 2017 Ministry of Health, National plan for managing insecticide resistance by malaria vectors 2016- 2020, December 2018 Ministry of Health, National Strategic Plan for Malaria Control 2016-2020, October 2016 Ministry of Health, National strategy for the implementation of free health care for women and children under five, December 2017 Ministry of Health, Planning guidelines 2018, January 2018 Ministry of Health, PNDS Monitoring and Evaluation Plan 2011-2020, January 2012 Ministry of Health, Sector performance report 2016, Health planning sector, March 2017 Ministry of Health, Strategic Plan for Tuberculosis Control 2018-2022, June 2017 General documents and working instruments Burkina Faso, National Plan for Economic and Social Development 2016-2020, July 2016 Computerized expenditure system, Budget implementation, State funding, Fiscal year 2017, on 30 February 2018 Computerized expenditure system, Budget implementation, State funding, Fiscal year 2018, on 30 February 2018 Computerized expenditure system (CID) draft settlement screen Computerized expenditure flow, Table of cost of activities by action and programme (thousands of FCFA) Integrated financial management system (CID) validation screen on 14 February 2018 38 BUDGETING IN HEALTH Ministry of the Economy, Finance and Development, Basic structure for drafting programme budget documents Ministry of Health, Criteria and key aspects for allocating state budget funds, management 2018 Ministry of Health, Key aspects and criteria for allocating the 2014 state budget Ministry of Health, Report on the workshop to review the criteria and keys for allocating state budget funds, May 2014 Ministry of Health, Total Ministry of Health expenditure by action, 31 December 2017 Ministry of Health, Total Ministry of Health expenditure by action, 31 January 2018 Ministry of Health, Total Ministry of Health expenditure by programme and type, 31 December 2017 Ministry of Health, Total Ministry of Health expenditure by programme and type, 31 January 2018 Ministry of Health, Transition Matrix Programme budget, National health development policy, July 2017 Ministry of Regional Administration and Decentralization, Validation form No. 2018-0913-9 of 05 February 2018 WAEMU, Training guide for Directive No. 06/2009/CM/WAEMU on the Finance Act in WAEMU WAEMU, Report on the implementation of the harmonized framework for public finances, second meeting of the Public finance monitoring unit, Lomé, 7-11 November 2016 Regulatory and institutional texts Act No. 040-2016/AN of 15 December 2016 on the Finance Act for the implementation of the state budget, 2017 financial year Act No. 052-2017/AN of 27 November 2017 on the Finance Act for the implementation of the state budget, 2018 financial year Act No. 008-2013/AN of 23 April 2013 on the general code of transparency in public financial management in Burkina Faso Act No. 039-2016/AN of 02 December 2016 on the general regulation of public procurement 39bIblIograPhy Act No. 073-2015/CNT of 06 November 2015 on the Institutional act on finance laws (LOLF) in Burkina Faso Circular No. 2016-0001/PRES of 22 June 2016 on the drafting of the government budget, financial year 2017 Circular No. 2017-0386/MINEFID/CAB on the role of the parties involved in the implementation of the programme budget in the transitional phase of the enforcement of the LOLF, February 2017 Decree No. appointing budget plan officers representing the Ministry of Health, Council of Ministers of 18 October 2017 Decree No. 2016- 601/PRES/PM/MINEFID of 08 July 2016 on the conceptual framework of state accounting Decree No. 2016-311/PRE/PM/MS/MATDSI/MINEFID of 29 April 2016 on free health care for women and children under five living in Burkina Faso Decree No. 2016-598/PRES/PM/MIINEFID of 08 July 2016 on general regulations on public accounting Decree No. 2017-0004/PRES/PM/MlNEFID of 12 January 2017 on the establishment, powers, organization and functioning of the National Plan for Economic and Social Development monitoring and evaluation system Decree No. 2016-753/PRES/PM/MS of 16 August 2016 on the organization of the Ministry of Health Decree No. 2018-0093/PRE/PM/MS of 15 February 2018 on the organization of the Ministry of Health Decree No. 2017-0049/PRES/PM/MINEFID of 1 February 2017 on procedures for awarding, executing and regulating public procurement and the delegation of public services Decree No. 2014-920/PRES/PM/MATD/MS/MEF/MFPTSS of 10 October 2014 on the transfer of powers and resources in health and hygiene from the State to the regions Decree No. 2009-108/PRES/PM/MATD/MS/MEF/MFPRE of 3 March 2009 on the transfer of powers and resources in the health sector from the State to municipalities Directive No. 06/2009/CM/WAEMU of 26 June 2009 on finance laws in WAEMU Directive No. 01/2009/CM/WAEMU of 27 March 2009 on the code of transparency in the management of public finances in WAEMU 40 BUDGETING IN HEALTH Directive No. 07/2009/CM/WAEMU of 26 June 2009 on the general regulation on public accounting in WAEMU Directive No. 08/2009/CM/WAEMU of 26 June 2009 on the government budget classification in WAEMU Directive No. 09/2009/CM/WAEMU of 26 June 2009 on the government chart of accounts (PCE) in WAEMU Interministerial order No. 2017-018/MINEFID/MATDS/MS of 12 January 2017 on the allocation of two billion two hundred and eighty-four million one hundred and forty-seven thousand three hundred and eighty-two (2,284,147,382) CFA francs representing the financial resources transferred to the municipalities for the powers transferred in the area of health with respect to recurring charges pertaining to the State budget, financial year 2017 Interministerial order No. 2017-020/MINEFID/MATDSI/MS of 24 January 2017 on the allocation of two billion nine hundred and ninety-nine million nine hundred and eighty-eight thousand and forty-five (2 999 988 045) CFA francs representing the financial resources transferred to the municipalities to support the powers transferred in the area of health with respect to investments pertaining to the State budget, financial year 2017 Joint order No. 2016-608/MS/MINEFID of 7 November 2016 on determining eligible expenditure in the context of free health care for women and children under the age of five in Burkina Faso Letter No. 2017-0386/MINEFID/CAB of 14 February 2017: role of the parties involved in the implementation of the programme budget during the transitional phase of the enforcement of the LOLF Order No. 2017-1244/MS/SG/DAF of 08 September 2017 amending the budget appropriations of programme 056 of the Ministry of Health, financial year 2017 Order No. 10/2009/CM/WAEMU of 26 June 2009 on the government financial operations table in WAEMU 41aPPendIxes APPENDIX 1: BUDGET-PLANNING PROCESS SINCE THE ADOPTION OF THE PROGRAMME BUDGET The process and various parties involved in the ministerial budget planning are as follows: Presidential circular launching the budget-planning process setting out the assumptions and budget framework, as well as the general and sector-specific priorities and the strategic budgetary choices adopted by the authorities (outline of the BP attached). Send the ministries’ and institutions’ reference allocations to the departments, by type of expenditure, to implement the programmes they are responsible for, as specified in the Multiyear budget and economic planning document drawn up by the Directorate general for the budget of the Ministry of Finance (general MTEF). Minister of Health sets up the Budget planning committee and subcommittees, according to the type of expenditure. This committee sends the various entities in the Ministry (Directorates, regional/ district health directorates, university/ regional hospitals, establishments, etc.): (1) the provisions granted to each of them according to the intrasector distribution and total amounts allocated to operating and/or transfer appropriations; (2) a request framework to ascertain the financial needs/cost of “activities” for each, according to the economic classification of the expenditure. The committee selects and consolidates the various requests sent by the entities and incorporates them in the actions and programmes; specific work on staff costs and investment according to the information requested by the Directorate general for the budget; validation by the ministerial authorities. DAF planning department includes all the information and tables needed to prepare the Ministry of Health draft programme budget in the CID (programming module), including the programmes’ performance framework; finalize the sector “Programme budget” document. Discussion of the ministerial budget proposal (summary table and “Programme budget” document) at a Budget Committee with the Ministry of the Economy, Finance and Development before inclusion in the draft budget/ government Finance Law, which will be presented and validated in the Council of Ministers before being submitted to the National Assembly (Draft Finance bill and all the documents prescribed by the LOLF including the ministerial “Programme budget” documents). APPENDIXES 42 BUDGETING IN HEALTH APPENDIX 2: LIST OF THE MINISTRY OF HEALTH’S PROGRAMME BUDGET’S ACTIONS AND ACTIVITIES Programmes, actions and activities 055 Access to health services 05501 Training of health personnel Ensure support for students at the end of their studies, interns, doctors undergoing specialized training; ensure the continuing training of staff; ensure the National School of Public Health continues to provide training + 2018 Ensure a single examination is organized 05502 Construction/rehabilitation of health infrastructure and 05503 Purchase and maintenance of health equipment Various investment projects 05504 Improving the availability of quality health products Purchase vaccines and consumables; purchase drugs; purchase therapeutic foods/micronutrients (consolidation of social safety net); purchase health products (reagents, malaria drugs, medical and blood consumables – social safety net); support dialysis unit and running of the blood transfusion centre 05505 Promoting health risk-sharing schemes Ensure the implementation of the free health care strategy 05507 Promoting traditional medicine and pharmacopoeia Organize the African Traditional Medicine Days 056 Health service delivery 05601 Community participation 2017: (no activity) 2018: Care for community-based health workers (CBHW) 05602 Reducing morbidity and mortality associated with endemic/epidemic diseases 2017: Specific funds (fight against neglected tropical diseases, response to epidemics, national disease control funds, funds to support the vulnerable persons programme, etc.); Specialist centres (tuberculosis, blindness) 2018: Specific funds (fight against neglected tropical diseases, response to epidemics, national disease control funds, support funds for the vulnerable persons programme, etc.); districts (monitor the running of the health districts); university, regional and district hospitals (monitor the running* of university and regional hospitals); specialist centres (tuberculosis, blindness); HIV/AIDS sectoral programme 05603 Quality mother and child health services Purchase contraceptive products; Organize National Immunization Days; + 2017: HIV/AIDS sector programme  05604 Disaster health management Supply the national fund for the fight against epidemics 05605 Health promotion 2017: Monitor the running of central administrations, regional health directorates (monitor the running of decentralized bodies); Districts (monitor the running of decentralized bodies); university, regional and district hospitals (monitor the running* of public health establishments); management of CHBW; health promotion in the towns (ensure commitments to the global fund to tackle certain diseases) 2018: Health promotion in towns (support health promotion activities in towns); 43aPPendIxes Programmes, actions et activités 057 Department of health services’ oversight and support 05701 Ministry of Health oversight, coordination and intersector collaboration Contribution to international organizations 2018: Functioning of central administrations; regional health directorates (functioning of regional health directorates); Contribution to international organizations 05702 Increase in health sector financing Drafting the Ministry of Health programme budget 05703 Management of financial and material resources Cover the expenses of medical evacuation (transport and hospitalization expenses); cover the project’s expenses, water/electricity, telephone, etc. 05704 Management of human resources Support the functioning of the professional bodies; + 2017, Ensure the organization of single screening 05705 Planning, monitoring and evaluation 2017: Action not selected 2018: Develop planning guidelines, hold National Plan for Economic and Social Development sector dialogue framework sessions, update health card, 05706 Building/rehabilitating and equipping administrative and educational infrastructure Various activities: office furniture equipment, computer equipment, building district management team offices, etc. 05708 Health information Support the running of the drug information and documentation centre + 2018: Develop national health accounts 05709 Health Research Promotion Support operations at the National malaria research and training centre, the Muraz centre, the Nouna health research centre + 2018: Supply the fund to support health research; Ensure the operation of the National institute of public health (INSP) 05710 Communication Support Ministry of Health communication APPENDIX 2: continued 44 BUDGETING IN HEALTH APPENDIX 3: VARIATION IN ALLOCATIONS BY PROGRAMME AND ACTION BETWEEN 2017 AND 2018 By programme and action 2017 2018 74.566.207 055 Access to health services Revised provisions 2017 Initial provisions 2018 Variation 2018/2017 (%) 05501 Training of health personnel 33.798.558 12.232.982 -64% per month 28.343.084 6.686.644 -76% 05502 Construction/rehabilitation of health facilities 20.010.259 17.800.429 -11% 05503 Purchase and maintenance of health facilities 20.089.074 18.195.826 -9% 05504 Improving the availability of quality health products 11.329.863 10.748.334 -5% 05505 Promoting health risk sharing schemes 16.219.240 16.125.742 -1% 05507 Promoting traditional medicine and pharmacopoeia 10.300 20.000 94% Total Programme 055 101.457.294 75.123.313 -26% 056 Health service delivery 05601 Community participation 28.372.483 55.191.939 95% per month 28.331.267 51.813.779 83% 05602 Reducing morbidity and mortality related to endemic/epidemic diseases 3.770.526 34.269.202 05603 Provision of quality maternal and child health services 648.617 1.550.000 139% 05604 Disaster health management 51.627 50.000 -3% 05605 Health promotion 36.598.090 2.359.529 -94% 05606 Health product quality assurance 610.414 1.566.894 157% Total Programme 056 70.051.757 94.987.564 36% 057 Department of health services’ oversight and support 05701 Ministry of Health oversight, coordination and intersector collaboration 13.571.042 17.623.612 30% per month 13.435.423 16.065.784 20% 05702 Increase in health sector financing 20.033 25.000 25% 05703 Management of financial and material resources 7.207.967 6.703.608 -7% 05704 Management of human resources 461.453 1.530.476 232% 05705 Planning, monitoring and evaluation – 43.000 0% 05706 Building/rehabilitating and equipping administrative and educational infrastructure 1.942.534 2.550.389 31% 05708 Health information 10.033 15.000 50% 05709 Health Research Promotion 879.246 1.162.702 32% 05710 Communication 118.387 30.000 -75% Total Programme 057 24.210.695 29.683.787 23% GENERAL TOTAL 195.719.746 199.794.664 2,1% Source : CID ; pour l’année 2017, état de situation tiré à partir du CID au niveau de la DAF/MS (service de l’execution budgétaire) Notes : 1. Dotations révisées : elles tiennent comptepour 2017, des deux Lois de finances rectificatives, des régulations/blocages instaurés par le MINEFID intégrés dans le CID, des modifications des crédits budgétaires au sein des programmes (dans le cadre de la fongibilité des crédits). 2. Investissement : crédits de paiement 45aPPendIxes APPENDIX 4: MINISTRY OF HEALTH’S BUDGETARY PROGRAMMES PERFORMANCE FRAMEWORK 2018-2020 Objectifs stratégique/ opérationnel Indicateurs d’impact /d’effet Référence Cibles Responsable Unité Année Valeur 2018 2019 2020 Programme 055 Accès aux sevices de santé Améliorer l’accès des populations aux services de santé de qualité Rayon moyen d’action théorique KM 2015 6,8 6,1 5,9 DGESS Pourcentage de la population vivant à moins de 5 km d’une formation sanitaire (FS) KM 2015 58,1 60 62,5 DGESS Action 05501 Formation du personnel de santé Produire des ressources humaines suffissantes et de qualité pour la santé Ration population / médecins RATIO 2016 15836 14000 13000 DRH Ratio population / IDE RATIO 2016 4108 <4000 <4000 <4000 DRH Ratio population / SFE 7778 INF7000 INF7000 INF7000 DRH Action 05502 Construction/Rehabilitation d’infrastructures sanitaires Développer les infrastructures sanitaires Pourcentage des formtions sanitaires répondant aux normes en infrastru RATIO 2016 NA 85 90 95 DGESS Action 05503 Acquisition et maintenance des équipements sanitaires Développer les équipements sanitaires et leur maintenance Pourcentage des formations sanitaires fonctionnelles selon les normes en équipements sanitaires % 2016 ND 65 70 75 DGESS Action 05504 Amélioration de la disponibilité des produits de santé de qualité Renforcer le circuit d’approvision- nement et de distribution des Produits de santé tie qualité Pourcentage des DMEG n’ayant pas connu de rupture des 20 molécules traceurs % 2016 28 DGESS Taux de rupture des MEG au niveau des DRD pour les 45 médicaments traceurseu % 2016 12,7 1,0 <1 <1 DGESS Action 05505 Promotion des mécanismes de partage des risques en matière de santé Améliorer l’accessibilité financière des populations aux services de sauté Proportion de la population couverte par un mécanisme de partage de risque maladie % 2016 12 25 30 35 DGESS Nombre de nouveaux contacts par habitant et par an NBRE 2016 1,02 1,3 1,4 1,5 DGESS 46 BUDGETING IN HEALTH Objectifs stratégique/ opérationnel Indicateurs d’impact /d’effet Référence Cibles Responsable Unité Année Valeur 2018 2019 2020 Action 05507 Promotion de la médecine et de la pharmacopée traditionnelles Renforcer la contribution de la médecine et de la pharmacopée traditionnelle a l’offre de soins de qualité Nombre de médicaments traditionnels enregistrés a la nomenclature nationale NBRE 2016 41 65 70 90 DGPML Nombre de tradipraticiens de santé autorisés a exercer NBRE 2016 29 200 250 300 DGPML Programme 056 Prestation des services de santé Réduire la morbidité , la mortalité pour une meilleure prevent°, des soins éfficaces et un changement des comportements Taux de mortalité maternelle RATIO 2016 341 243 243 243 DGESS Taux de mortalité des enfants de moins de 5 ans RATIO 2016 62,75 62,75 62,75 62,75 DGESS Action 05601 Participation communautaire Promouvoir les interventions intégrées à base communautaire en matière de santé Nbre d’ONG sous contrat de prestation avec le Ministère de la Santé NBRE 2016 252 252 252 252 DGS Nombre de villages couverts par les OBC-E NBRE 2016 8000 8000 8000 8000 DGS Action 05602 Réduction de lamobilitéet de la mortalité endémo-épidémies Promouvoir les interventions intégrées à base communautaire en matière de santé Nbre de nouveaus contacts par habitant et par an dans les structures de soins de ler échelon (CM et CSPS) NBRE 2016 1,02 1,3 1,4 1,5 DGESS Taux d’occupation des lits au niveau des hopitaux % 2016 50,5 60 65 70 DGS Action 05603 Offre de services de qualité en faveur de la santé de la mère et de l’enfant Améliorer la santé de la mère et de l’enfant Taux d’ accoucheinents assistés % 2016 80,9 >=87 >=90 >=90 DGESS Taux de réalisation des césariennes parmis les naissances attendues % 2016 >=3,5 >=3,8 >=3,9 >=4 DGESS Taux de couverture vaccinale des enfants en penta3 % 2016 103 100 100 100 DGESS Action 05604 Gestion sanitaire des catastrophes Renforcer la gestion sanitaire des catastrophes Taux de prise en charge des victimes des catastrophes % 2016 NA 80 80 80 DGS Proportion des hopitaux disposant d’un plan de riposte <plan blanc> % 2016 100 100 100 100 DGS APPENDIX 4: continued Objectifs stratégique/ opérationnel Indicateurs d’impact /d’effet Référence Cibles Responsable Unité Année Valeur 2018 2019 2020 Action 05605 Promotion de la santé Améliorer l’hygiène, I’assainissement et les comportements favorables á la santé Pourcentage de comités régionaux d’hygiène fonctionnels % 2016 ND 100 100 100 DGS Taux de réalisation physique du plan de communication en faveur de l’hygiène et de l’assainissement % 2016 >=85 >=85 >=85 DGS Action 05606 Assurance qualité des produits de santé Renforcer le système d’assurance qualité des produits de santé Taux de conformité des produits pharmaceutiques controlés % 2016 >=95 >=95 >=95 DGPML Nombre de produits controlés en post marketing NBRE 2016 339 360 370 380 DGPML Programme 057 Pilotage et soutien des services du Ministère de la Santé Renforcer les Capacités institutionnelles, organisationnelles, la gouvernance et le leadership dans le secteur de la santé Proportion des structures disposants de tous les outils de pilotage et de bonne et goouvernance % 2016 ND 100 100 100 Cab. Min. Action 05701 Pilotage, coordination des actions du Ministère de la Santé et collaboration intersectorielle Améliorer le pilotage stratégique des actions du Ministère de la santé et la collaboration intersectorielle Taux de réalisation des revues du secteur de la santé % 2016 100 100 100 100 Cab. Min. Nombre de CASEM santé tenus NBRE 2016 2 2 2 2 DGESS Action 05702 Accroissement des financements du secteur de la santé Mobiliser les financements au profit du secteur de la santé Taux de mobilisation des ressources additionnelles % 2016 ND >=90 >=90 >=90 DAF Taux d’absorption des ressources financières allouées % 2016 94,22 >=87 >87 >=88 DAF Proportion du budget de l’Etat allouée au Ministère de in Santé % 2016 12,4 13,5 14 14,5 DAF Action 05703 Gestion des ressources financières et matérielles Améliorer la gestion des ressources financières et matérielles mobilisées Pourcentage des structures ayant fait l’objet d’audits financiers % 2016 ND 100 100 100 SG Nombre d’inventaires de matériels realisés NBRE 2016 ND 2 2 2 DAF APPENDIX 4: continued Objectifs stratégique/ opérationnel Indicateurs d’impact /d’effet Référence Cibles Responsable Unité Année Valeur 2018 2019 2020 Action 05704 Gestion des ressources humaines Rationnaliser la gestion des ressources humaines pour la santé Pourcentage de CSPS remplissant les normes minima en personnel % 2016 93,2 >=95 >=95,3 >=96 DGESS Action 05705 Planification, suivi et évaluation Améliorer le processus de planification de suivi et d’évaluation au sein du secteur de la santé Proportion de structures disposant d’un plan d’action annuel % 2016 100 1000 100 100 DGESS Taux d’exécution physique des plans d’action % 2016 ND >=85 >=85 >=85 DGESS Action05706 Construction/réhabilitation et équipement d’infrastructures administratives et éducatives Développer les infrastructures administratives et éducatives, et leurs équipements Pourcentages des ECD fonctionnelles selon les normes en infrastructures % 2016 ND 100 100 100 DGESS Pourcentage des infrastructures éducatives publiques conformes aux normes % 2016 ND 90 90 90 DGESS Action 05708 Information sanitaire Développer l’information sanitaire Taux de promptitude des rapports d’activités des Formations Sanitaires publiques de soins % 2016 ND >=85 >=85 >=85 DGESS Taux complétude des rapports d’activités des Formations Sanitaires publiques de soins % 2016 97,1 100 100 100 DGESS Action 05709 Promotion de la recherche pour la santé Développer la recherche pour la santé Proportion de protocoles d’études et de recherches validés par un comité d’éthique ayant fait l’objet d’un rapport % 2016 ND 100 100 100 DGESS Proportion des résultats de recherches utilisés dans le processus de prise de décision % 2016 ND 60 65 70 DGESS Action 05710 Communication Améliorer la communication pour le changement de comportement des population Taux de réalisation physique annuel du plan de communication en faveur de l’hygiène et de l’assainissement % 2016 ND >85 >85 >85 DGS Source: Budget – expenditure, Ministry of Health. Note: an error has crept into the strategic objective for action 05602: Reducing endemic/epidemic morbidity and mortality should in fact be “Improve the supply of quality health services”. APPENDIX 4: continued For additional information, please contact: Health Systems Governance and Financing Department Universal Health Coverage and Health Systems Cluster World Health Organization 20, avenue Appia 1211 Geneva 27 Switzerland Email: healthfinancing@who.int Website: http://www.who.int/health_financing HEALTH FINANCING CASE STUDY No 11 BUDGETING IN HEALTH

Hélène Barroy Françoise André Abdoulaye Nitiema TRANSITION TO PROGRAMME BUDGETING IN HEALTH IN BURKINA FASO: STATUS OF THE REFORM AND PRELIMINARY LESSONS FOR HEALTH FINANCING HEALTH FINANCING CASE STUDY No 11 BUDGETING IN HEALTH

Hélène Barroy Françoise André Abdoulaye Nitiema TRANSITION TO PROGRAMME BUDGETING IN HEALTH IN BURKINA FASO: STATUS OF THE REFORM AND PRELIMINARY LESSONS FOR HEALTH FINANCING HEALTH FINANCING CASE STUDY No 11 BUDGETING IN HEALTH Transition to programme budgeting in health in Burkina Faso: Status of the reform and preliminary lessons for health financing / Helene Barroy, Françoise André, Abdoulaye Nitiema WHO/UHC/HGF/HEF/CaseStudy/18.11 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. 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TABLE OF CONTENTS Acknowledgements ....................................................................................................................................................v Executive Summary ..................................................................................................................................................vi Introduction .................................................................................................................................................................1 1. Context of the reform ................................................................................................................................ 3 1.1 Changes to the subregional regulatory framework ..................................................................4 1.2 Change to Burkina Faso’s legislative and regulatory framework ......................................... 5 1.3 Changes within the health financing system and alignment with public financial management reforms .......................................................................................................................... 7 2. Process of transition to the programme budget .......................................................................11 2.1 Programme budget: from preparation to institutionalization for all ministries (1998-2015) .........................................................................................................................11 2.2 The Ministry of Health’s transition to a programme budget: alignment with national health strategies ....................................................................................................... 12 2.3 Changing role of stakeholders in the reform ............................................................................. 15 3. Structure and content of the Ministry of Health’s budgetary programmes .............. 18 3.1 Structure of the Ministry of Health’s programme budget .................................................... 18 3.2 Analysis of the content of the Ministry of Health’s budgetary programmes ................ 19 3.3 Implications of the reform for specific health projects (immunization, HIV/AIDS, malaria, tuberculosis) .....................................................................................................22 4. First effects of the reform (2017-2018): progress and challenges ...................................25 4.1 Moving towards an end to annual deferred budgetary programmes? ............................25 4.2 Towards more flexibility in spending? ......................................................................................... 26 4.3 Towards financial accountability that is of benefit to the sector? ......................................27 Summary of progress, challenges and recommendations ............................................................. 30 Bibliography ................................................................................................................................................................32 Appendixes...............................................................................................................................................................40 Appendix 1: Budget-planning process since the adoption of the programme budget .............40 Appendix 2: List of the Ministry of Health’s programme budget’s actions and activities ......... 41 Appendix 3: Variation in allocations by programme and action between 2017 and 2018 .........43 Appendix 4: Ministry of Health’s Budgetary programmes Performance Framework 2018-2020 ............................................................................................................44 List of tables Table 1: Summary of the WAEMU Harmonized Public Financial Management Framework .......4 Table 2: Key aspects of budget reform agenda in Burkina Faso ........................................................... 5 Table 3: Main items related to planning and implementation of reform plans and sector finance strategy ........................................................................................................................6 Table 4: List of purchasers and payment methods used..........................................................................8 Table 5: Health financing strategy: challenges and remedial action for public expenditure on health........................................................................................................................10 Table 6: Extract of the structure of the line budget, Ministry of Health (before 2017) ............... 15 Table 7. Alignment between the new budgetary programmes and the Ministry of Health’s reorganization (2018) .........................................................................................................17 Table 8: Ministry of Health’s programme budget’s programmes and actions (2018) .................. 21 Table 9: Allocation of pre-reform and post-reform immunization expenditure ...........................23 Table 10: Actions and activities posted under the Presidency’s “Fight against HIV, AIDS and STDs” budget plan ...........................................................................................................24 Table 11: Budget allocation of malaria prevention and management expenditure in the programme budget (post-reform) .........................................................................................24 Table 12: Implementation of the health budgetary programmes (2017) ............................................27 Table 13: Extract from the Ministry of Health programme budget’s Performance Monitoring (2018-2020) ................................................................................................................... 28 List of figures Figure 1: History of the transition to the programme budget in Burkina Faso ............................... 12 Figure 2: Mapping of 2011 PNDS objectives, 2011-2018 Ministry of Health budgetary programmes and 2016 PNDS objectives .....................................................................................16 Figure 3: Structure of the Ministry of Health’s budgetary programmes in Burkina Faso ........... 19 Figure 4: Distribution of budget appropriations by programme in 2017 and 2018, Ministry of Health ............................................................................................................................... 26 v ACKNOWLEDGEMENTS The report was written by Hélène Barroy (WHO Governance and Health Financing Department), Françoise André (Public Financial Management consultant, WHO), and Abdoulaye Nitiema (Director, Studies and Statistics, Ministry of Health, Burkina Faso). It is the result of data collection and analysis work conducted by Hélène Barroy, Françoise André and Mathurin Koné (WHO consultant, public finance) in Burkina Faso between January and March 2018. Input was also provided by the WHO country office, in particular by Dr Alimata Diarra (Burkina Faso Representative), Dr Fatimata Zampaligré (health systems focal person), Dr Seydou Coulibaly (Intercountry Support Team, IST-WA) and Alexis Bigeard (Intercountry Support Team, IST-WA). We are grateful for their contributions. The authors would also like to thank the WHO African Regional Office, in particular Dr Grace Kabaniha, for their support in the successful conduct of the study. The analysis was performed in close collaboration with the Burkinabe government authorities. The authors wish to extend their heartfelt thanks to the following individuals from the Ministry of Health and the Ministry of the Economy, Finance and Development for their valuable technical contributions to this study: For the Ministry of Health: S.E. Dr Nicolas Méda, Minister of Health, Dr Hidnibba Francine Ouedraogo, Secretary general at the Ministry of Health, Dr Sylvain Dipama, Technical adviser at the Ministry of Health, Dr Isaie Medah, Director general of public health, Dr Samba Dialllo, Director general of health care provision, Dr Pierre Yameogo, Technical secretary of universal health coverage, Mr Daouda Akabi, Director of administration and finance, Dr Yacouba Sawadogo, Coordinator of the National malaria control programme and their teams. For the Ministry of Finance, Economy and Development: Ms Brigitte Compaore, Deputy director general of the budget, Mr Vincent de Paul Yameogo, Director of budget reform. The authors also wish to thank Fadhi Dkhimi (WHO) and Alexis Bigeard (WHO) who reviewed the report, as well as the local partners consulted during the conduct of the study, in particular the European Union (Bart Callawaert), WAEMU (Issa Sawadogo) and the World Bank (Bali Ouattara, Benoit Mathivet). The conclusion of this report were shared, discussed and formally revised by the authorities of the Ministry of Health of Burkina Faso during the seminar organised in Ouagadougou by the Ministry of Health and the WHO on programme-based budget in health on 11-12 July 2018. The study was funded with support from GAVI’s Sustainability Strategic Focus Area initiative and DFID’s Making Country Health Systems Stronger programme. vi BUDGETING IN HEALTH EXECUTIVE SUMMARY Budget formulation can play a critical role in optimizing health sector performance, though it is often overlooked. Public performance and expenditure in the health sector depends on an effective allocation and flow of resources within the health system. Near the end of the 1990s, Burkina Faso initiated profound reforms in the management of public finances, in line with regulations set by the West African Economic and Monetary Union (WAEMU). The pivotal measure was the introduction of budgetary programmes, which marked a shift away from purely input-based budgeting. Parliament approved the programme-based budget in 2017, 20 years after the reforms began. Burkina Faso became the first country in the WAEMU region to adopt a programme budget. The Ministry of Health (MoH) was one of the first ministries to institute the reforms. The MoH created a budget including three major budgetary programmes which were aligned with the priorities laid out in the national health plan, the Plan National de Développement Sanitaire (PNDS). Burkina Faso’s shift to a programme-based budget in health offers interesting lessons for other countries engaged in similar reforms. The following lessons on the definition and implementation of budgetary programmes emerged: Defining the content of budgetary programmes is a central issue in the health sector. To harmonize content with sector priorities, key actors in the health and financial sectors must work together to define the programmes and review them periodically. Budgetary programmes can reduce the financial fragmentation that may be a remnant of input-based budgeting. By integrating specific disease-related interventions into broader budgetary programmes, programme-based budgeting may also further reduce financial duplication and fragmentation. Reforms should include a transition across different levels of governance. Along with reforms relating directly to public finance, legal and institutional elements should also be priorities. Legal aspects may include updating the regulatory framework. Institutional aspects may include strengthening budgetary planning capacities within each sector. Reforms must go beyond mere changes in budget formulation and should include improved management of expenditures. Reforms lay the foundation for more flexible spending that can adapt to changes within the sector and which allows for reallocations within budgetary programmes. When accompanied by a quality performance monitoring framework, programme-based budgets make it possible to monitor financial and operational performance within a single framework. Policy-makers can use performance information to guide future budgetary decisions. While Burkina Faso is well advanced in the implementation of a programme-based budget, particularly in the health sector, some challenges remain. In 2018, the MoH launched a review of the content of two of the main budgetary programmes. The goal was to improve quality and align the programmes with the department’s new strategic direction. Other aspects of the budget that require additional work include: strengthening the definition of the performance monitoring framework; building the programme budgeting capacity of programme directors vii and their teams; tightening the links between budget reform and the health financing strategy, notably the creation of the health insurance scheme, the Régime d’assurance maladie universelle (RAMU); and improving monitoring to ensure coherence and coordination.

1IntroductIon INTRODUCTION Most countries have begun a transition to programme- or objective-based budgets, to better align with public policy priorities and to meet the need for accountability and transparency.1 In addition to changes in the presentation of budget documents, this reform triggers shifts in budgeting and expenditure management systems, which require closer collaboration between finance and line ministries. In the health sector, it is often a challenge to identify the outlines and content of budgetary programmes. This reform has the potential to improve the allocation of funds according to sector priorities. Health authorities must get involved during the preparation phase if the process is to deliver the expected benefits. Development partners, too, are frequently uninformed during such transitions and need to better understand the implications. The World Health Organization (WHO) began a work programme in 2018 on health budget structure issues. The WHO Department of Health Systems Governance and Financing (HGF) wanted to examine the process and the effects of health budget reform and offer more support to countries undergoing such a transition. The HGF divided this work into three principal areas: 1. a global review of health budget structures 2. case studies on the transition to programme budgets in the health sector 3. training and support for health budget reform. Burkina Faso was identified as one of the first countries to be studied in the WHO African Region. In 2017, it had crafted a budget for all ministries around major public policy objectives and priorities. It had completed a pilot phase and was the first WAEMU country to have institutionalized programme budgets. The WHO chose Burkina Faso to identify the lessons learned and to share these lessons with other countries in the subregion and beyond. The specific goals were: to analyse the structure of the health budget before and after the reform; to document the transition from a line budget to a programme budget, focusing on specific projects such as immunization; to analyse the initial effects of the reform from a sector perspective; and to recommend any possible changes. The study began with a review of budgetary and legal documents, followed by data collection and interviews with key stakeholders in the health and finance sectors between January and March 2018. The results were shared with the MoH in May 2018 then reviewed and approved in July 2018. The report begins with a contextual review of developments in the WAEMU regulatory framework and its conversion into national law with respect to the programme budget and public financial management. The report also surveys developments in health financing and their links to public finance. The second part focuses on the budget reform process, analysing the stages in the transition and roles of various players. The third part explores the structure and content of the MoH’s three budgetary programmes. 2 BUDGETING IN HEALTH At the request of the partners supporting and involved in the study, this includes an analysis of the inclusion in the budget formulation of specific interventions, such as those for HIV/AIDS, malaria, tuberculosis, as well as immunization. The last section analyses the initial impact of the reform on budget planning, flexibility in managing expenditures, and accountability. The report concludes with a summary of the progress and challenges and includes recommendations on adapting the reform to best address the needs of the sector in Burkina Faso. 3context of the reform In 2009, the WAEMU agreed to a harmonized public finance framework applicable to all member states following discussions that had been held since the early 2000s. Some of the notable measures included introducing results-based management and a programme budget tool. Between 2013 and 2016, Burkina Faso amended the regulatory and legislative framework required by WAEMU into its own legislation. In 2017, it became the first WAEMU country to adopt a programme budget.I These discussions about public financial management reform prompted similar discussions about the implications for the health sector. 1.1 CHANGES TO THE SUBREGIONAL REGULATORY FRAMEWORK In 2009, WAEMU countries adapted the Harmonized Public Financial Management Framework which had been drafted in the late 1990s to international standards and best practices in financial management. The WAEMU Council of Ministers framed their work around six directives (see Table 1). The aim of this regulatory framework was to ensure better outcomes and more effective public policies. The new rules modernized budgetary management. They introduced I Burkina Faso officially adopted the term “programme budget” , which will be used in the rest of this report. budgetary discipline that facilitated sustainable policies and a more efficient use of public resources, set within a framework of major constraints. The approach was designed to strengthen the link between national development strategies, sector policies and the state budget. The framework established a results-based culture, giving operational staff responsibility for the results achieved and introducing greater clarity, transparency and accountability to the management of public affairs. The transition to a programme budget is one of the key elements of the WAEMU Finance Law Directive (No. 06/2009). In Section III, Article 12, “content of the year’s finance laws”, the directive specifies that “within ministries, appropriations are broken down into programmes[...]” The article defines a programme as “consolidating the appropriations set aside to implement an action or a coherent set of measures that represent a clearly defined medium- term public policy.” These programmes are combined with “specific goals, agreed on the basis of public interest and expected outcomes.” These outcomes, “measured by performance indicators, are regularly evaluated and embodied in a [annual] performance report.” Adapting the directives to national law varies according to the directive and the state. The WAEMU member states had committed to adapting the directives to their national legislation in December 2011, with a deadline of January 2017 for full implementation of the programme budget. In April 2017, the 1. CONTEXT OF THE REFORM 4 BUDGETING IN HEALTH WAEMU Council of Ministers extended this deadline to 1 January 2019.II In December 2012, Senegal became the first member state to conform with the Transparency Code. Burkina Faso followed. However, it was the last to conform with the Finance Law and the decrees pursuant to it. Other countries have amended their regulatory frameworks more swiftly although implementation has been uneven between states. By the end of 2016, only Burkina Faso had decided to adopt a programme budget for II Press release of the Ordinary Session of the Council of Ministers of the Union, Dakar, 31 March 2017 “The Council examined the status of implementation of the Directives of the Harmonized Public Financial Management Framework on 31 December 2016 (...). With respect to the states’ implementation of these reforms, the Council invited the Ministers of Finance to complete the implementation of the directives and in particular the implementation of the programme budget by 1 January 2019 at the latest.” In December 2016, Senegal’s National Assembly voted to postpone the date that the new finance laws would come into effect to 1 January 2020. the 2017 fiscal year, in line with the initial deadline set by WAEMU. Other member states (Benin, Côte d’Ivoire, Mali and Senegal) had planned implementation in some ministries or future implementation in the state budget (2018 in Niger, 2019 in Togo).4 1.2 CHANGES TO BURKINA FASO’S LEGISLATIVE AND REGULATORY FRAMEWORK Burkina Faso has made a considerable effort to update and strengthen its legislative and regulatory framework for public finance. All laws and decrees were incorporated between 2009 and 2016, streamlining a regulatory framework for WAEMU directives (see Table 2). Burkina Faso instituted this process in the late 1990s. In 2001, the authorities introduced Table 1: Summary of the WAEMU Harmonized Public Financial Management Framework Directives of the WAEMU Harmonized Public Financial Management Framework Main guidelines of the Directives Directive No. 01/2009/CM/WAEMU of 27 March 2009 on the Code of transparency in public financial management in WAEMU General umbrella directive for five others, which establishes the principles and obligations that the member states must respect on managing government and other government departments’ funds in their legislation and practice. Directive No. 06/2009/CM/WAEMU on Finance laws in WAEMU Sets out the rules on the scope and classification of the Finance laws, their content, presentation, macroeconomic framework, preparation and votes, as well as the implementation and checks on the Finance laws and, finally, the transitional provisions. Directive No. 07/2009/CM/WAEMU on the General regulations on public accounting in WAEMU Sets out the rules governing the management of public accounts, securities or assets. Directive No. 08/2009/CM/WAEMU on the government budget classification in WAEMU Sets out the basic rules and principles for presenting budget operations. Directive No. 09/2009/CM/WAEMU on the government chart of accounts in WAEMU Lays down the basic rules for the accounting of financial and budget operations in the member states. It determines the aim of the general accounting, the standards, rules and procedures on keeping and producing the state’s accounts and financial statements. Directive No. 10/2009/CM/WAEMU on the government financial operations table in WAEMU Specifies the general principles on the drafting and joint presentation of statistics on the state’s financial operations that form the basis of multilateral monitoring. Source: WAEMU, 2009 5context of the reform the Medium-Term Expenditure Framework (MTEF) to improve the planning of resources. The MTEF set out budget allocations, or envelopes, for each ministry based on inputs such as operations, personnel, goods and services, and transfers.III The MTEF is updated every year to follow macroeconomic forecasts as closely as possible. In July 2002, authorities drafted a plan of action to strengthen budget management then started to update budgetary systems based on results-based management (RBM). They reflected this commitment with a strategy to strengthen public finance in April 2007 then again with the economic and financial sector policy for 2011–2020 (see Table 3). The guidelines for results-based management are laid down within these frameworks. III The goals of the global MTEF are: (1) to define a coherent and realistic multi-year resource framework based on an accurate macroeconomic framework, (2) to identify medium-term sectoral financial budgets aligned with the Government’s strategic priorities and budgetary constraints, and (3) to ensure a predictable financial framework for ministries to develop and implement strategies and achieve the expected results. In addition to changes that affect budget planning, public finance reforms also have an impact on expenditure practices, namely by introducing the principle of “decentralizing authorization” (Article 70, Institutional Act on Finance Laws – LOLF). Previously, the Minister of Finance served as the sole primary authorizing officer in confirming appropriations. Decentralization allowed for the transfer of this prerogative to sector ministers including the Minister of Health. They became the chief authorizing officers for their ministries’ appropriations. They assumed responsibility for expenditures and payments as they followed through with ministry commitments. They could also delegate their powers for appropriation commitments within their ministry (Article 67), specifically to programme managers.IV Further, the sector ministries became responsible for controls over IV In the MoH, commitment is delegated to the Department of Financial Affairs (DAF) and may subsequently be transferred to programme managers; the cellule d’ordonnancement is responsible for authorizations (currently still within the Ministry of the Economy, Finance and Development thought it will be transferred to the sector ministry). Table 2: Key aspects of budget reform agenda in Burkina Faso Directives of the WAEMU Harmonized Public Financial Management Framework Burkina Faso – National legislative and regulatory transposition Directive No. 01/2009/CM/WAEMU on the Code of transparency in public financial management in WAEMU Law No. 008-2013/AN of 23 April 2013 on the general code of transparency in public financial management in Burkina Faso Directive No. 06/2009/CM/WAEMU on Finance laws in WAEMU Institutional act No. 073-2015/CNT of 06 November 2015 on finance laws, which came into effect on 1 January 2016 Directive No. 07/2009/CM/WAEMU on the general public accounting regulations in WAEMU Decree No. 2016-598/PRES/PM/MINEFID of 08 July 2016 on general public accounting regulations Directive No. 08/2009/CM/WAEMU on the government budget classification in WAEMU Decree No. 2016-600/PRES/PM/MINEFID of 08 July 2016 on the government budget classification Directive No. 09/2009/CM/WAEMU on the government chart of accounts in WAEMU Decree No. 2016-601/PRES/PM/MINEFID of 08 July 2016 on the conceptual framework for public sector accounting Directive No. 10/2009/CM/WAEMU on the government financial operations table in WAEMU Decree No. 2016-602/PRES/PM/MINEFID of 08 July 2016 on the government financial operations table Source: WAEMU, 2009 and Burkina Faso, www.legiburkina.bf5 6 BUDGETING IN HEALTH different stages in the chain of expenditure. In 2012, government expenditure verification unitsV were set up in the ministries. This supported efforts toward the decentralization of authorizations, freed up central monitoring V The units are responsible for verifying and validating the expenditure, from the administrative phase through to the payment; a verification unit is made up of a financial check cell, an authorizations cell and a payments cell, which are hierarchically and operationally linked to the parent organization, namely the Ministry of the Economy, Finance and Development’s Office of public procurement and financial commitments, Office for scheduling and accounting, and Public accounting office and treasury, respectively. departments, and reduced the time taken to authorize expenditures.VI Another principle governing public expenditure is that of asymmetric fungibility. Burkina Faso introduced this standard in the Institutional Act of 2015. This principle maintains that spending can vary upwards or downwards within each budgetary VI In accordance with the WAEMU directive, the LOLF enshrines the increased powers of the Minister of Finance through regulatory powers, which enables them to maintain the budgetary and financial balance stipulated in the current Finance Act, cancel appropriations and make the authorizing officers’ use of appropriations subject to the availability of cash (Art. 69). Table 3: Main items related to planning and implementation of reform plans and sector finance strategy Plan of action to strengthen budget management 2002-2006 Strategy to Strengthen Public Finance 2007-2015 Economic and financial sector policy 2011-2020 Budget planning Strengthen the quality and transparency of the Finance Law (with an emphasis on frameworks for medium-term expenditure and results-based management (RBM)) - Transparent and efficient public expenditure management process - Plan expenditure according to the strategic allocation principle and results-based budgeting - Strengthen stakeholder accountability - Results-Based Management and introduction of Programme Budget approach - Strengthen consistency of the macroeconomic framework, medium-term fiscal plans and budget allocations - Adjust tools to the Results-Based Management approach and the Programme Budget - Support in sector public policy-making - Bring the legislative and regulatory framework in line with WAEMU directives - Capacity building of budget management stakeholders according to the PB approach Budget implemen- tation Strengthen the monitoring of budget implementation (system and data) - Transparent and efficient public expenditure management process - Strengthen stakeholder accountability - Complete and reliable budget implementation data - Develop statistical output - Adjust the I.T. system to the PB - Improve the spending flow by creating verification units in sector ministries along with the flow in terms of procedure and participants Controls Strengthen controls on the implementation of the budget Efficient monitoring system aligned with international standards Consideration/further development of the monitoring system in principle and adjusting it to PB requirements Sources: Plan of action to strengthen budget management and Strategy to strengthen public finance from “Evaluation of Public Financial Management Reform in Burkina Faso, 2001–2010, DANIDA, Final Country Case Study Report, June 2012”6; Economic and financial sector policy: Ministry of the Economy and Finance, Economic and Financial Sector Policy 2011-2020, Economic and financial sector policy 2011-2020, April 20117 7context of the reform programme. Wage expenditure remains under control. It can only fall, not rise, while capital expenditure can only rise, hence the asymmetry. This principle is supposed to apply to each budgetary programme, providing greater autonomy to the ministry. However, it contradicts a programme model that would enable full flexibility on all items of expenditure within the same programme.VII 1.3 CHANGES WITHIN THE HEALTH FINANCING SYSTEM AND ALIGNMENT WITH PUBLIC FINANCIAL MANAGEMENT REFORMS Alongside these reforms to public financial management, Burkina Faso began a review in 2010 to change the health financing system. Between 2013 and 2017, the MoH developed a health financing strategy (2017–2030)8 then presented it to the Council of Ministers in June 2017.VIII In 2015, public funds accounted for 33% of total current health expenditures. External funds accounted for 22%.9 Between 2015 and 2016, the share of direct payments decreased from 36% to 31% of total health expenditures, most likely attributable to the user fee removal VII Fungibility (LOLF, Art. 17, section 2): “... within the same programme, the authorizing officers may amend the type of current appropriations and use them, if they are free to do so, in the following cases: – staff appropriations to increase appropriations for goods and services, transfer or investment line items; – appropriations for goods and services and transfers to increase investment appropriations.” VIII The financing strategy (October 2017 version) is available but has not been formally adopted by the Government. Following a review by the Council of Ministers, the hope is to develop an operational plan based on this strategy, enabling progress to be made towards concrete implementation. In November 2018, the operational plan was finalized and submitted to the Cabinet for approval. policy. External funds financed almost half of public expenditures (on average 47% of public health expenditures between 2012 and 2015). In absolute terms, budgetary allocations nearly quadrupled over 10 years, rising from around 34 billion CFA francs in 2005 to 132 billion in 2014 (and 180 billion in 2016). As a share of total public expenditures, health expenditures remained relatively stable between 2012 and 2015, averaging 12%. Historically, Burkina Faso is one of the countries in the African region that has given high priority to its public spending to the health sector. In the past, the health financing system had been characterized by highly fragmented funding. Mapping conducted in 201410 indicated approximately 30 schemes, most of which were attributable to free programmes set up since 2006. Two funds covered a limited range of health services for employees in the formal private sector (National Social Security Fund – CNSS) and among civil servants (Civil Servants’ Pension Fund – CARFO).IX A 2011 study suggested around 200 entities were engaged in community- based health insurance, of which 188 are in operation.X These mutuelles covered 140,000 beneficiaries, fewer than 1,000 beneficiaries per entity. They covered services that were generally part of the minimum and IX CNSS package includes maternal and child health services, HIV/AIDS treatment, and medical evacuation for treatment abroad. CARFO extended coverage in 2009 to provide medical and surgical assistance, and care and treatment in case of work accidents. X According to a 2011 study, these include 131 community- based health insurance mutuelles, 38 professional mutuelles, 22 other cost-sharing schemes, nine other prepayment schemes, and five village solidarity funds (ASMADE. Inventory of mutual societies for universal health coverage in Burkina Faso, October 2011)11 8 BUDGETING IN HEALTH complementary health care package in first- and second-level health facilities. The payment system for health services encompasses a range of methods, due to the fragmentation of schemes and to the use of multiple payment systems for the same scheme. A WHO study on payment for health services charts the various mechanisms.12 The overall goal of the new health financing strategy is to “remove barriers to access to health care.” The strategy lists 17 measures to address the challenges. These include the implementation of a universal health insurance scheme, RAMU. This would be a mandatory pre-financing system, subsidized with public funds. Experts have identified coverage of the formal public and private sector as a priority. Community-based health insurance schemes would cover the informal sector, although the terms have yet to be defined. Authorities will also have to determine how to coordinate RAMU with existing funding systems, particularly those for free care programmes. Many of the challenges identified in the health financing strategy relate to the improved management of public resources, with a clear link to reforms in the management of public finances. The strategy points to the implementation of results-based management and a programme budget as tools for improved “oversight/governance/monitoring of the sector’s financing system” (see Table 5). This would produce a beneficial orientation between public finance and health financing reform. Decentralization is linked to these public financial management reforms and directly Table 4: List of purchasers and payment methods used Overall budget allocation Allocation by budget item Payment by procedure Payment on a case-by- case basis (flat rate) Capitation Payment by results Ministry of Health – DAF X X       Ministry of Health – Health development programme X X X Ministry of the Economy, Finance and Development/Ministry of Territorial Administration and Decentralization/Ministry of Health X Generic medicines purchasing agency           X National council for the fight against HIV/AIDS and sexually- transmitted infections X NGO X X X X     Mutual health insurance X Private insurance     X       Universal health insurance scheme       X  X   TFPs (regulated) X X Source: WHO, 201712 9context of the reform affects the health sector. The process, which began in 2004,13 provides for the transfer of skills and resources from the state to the municipalities for level-1 facilities, health centres (Centre de Santé et de Promotion Sociale).14 The regions were assigned jurisdiction over level-2 facilities, health centres with surgical units.15 This involves a transfer of skills to build, staff, and manage these health facilities to deliver minimum (level-1) and complementary (level-2) care packages. This reform has several implications for sector financing. The transition to the programme budget involves grouping two types of transfers for the municipalities under a single government “transfer of resources to local and regional authorities” programme and “transfer to the health sector” action. In principle, the MoH no longer manages the subsidies to operate and invest in level-1 health facilities.XI In practice, however, only skills, and therefore resources, are transferred to the municipalities without any transfer to the regions. The human resources associated with the delivery of minimum and complementary care packages should also be transferred to lower levels, though this has not been implemented. Ministry staff are part of the XI These funds are subject to two interministerial orders (Ministry of the Economy, Finance and Development, the Ministry of Territorial Administration, Decentralization and Social Cohesion, and the MoH) on the allocation of transferred financial resources and orders drafted by the MoH DAF (based on the Directorate General of Sector Studies and Statistics Proposals), prior to being sent to the Ministry of the Economy, Finance and Development’s General Directorate for Regional Development (DGDT) for their operational implementation and transfers at the start of the year. One relates to funds earmarked for investments in buildings to standardize basic health facilities and the other, sums intended for recurring costs in basic health facilities. civil service and have demonstrated some resistance. Discussions have been underway since 2017 to create a hospital public service that would be separate from the national civil service. All jobs in health facilities could be associated with this new body. Under the programme budget, staff costs are charged to MoH programmes (see section 4.2) but are still implemented for remuneration by the Ministry of the Economy, Finance and Development. 10 BUDGETING IN HEALTH Table 5: Health financing strategy: challenges and remedial action for public expenditure on health Task Challenges Measures Mobilizing resources Capacity of the Ministry of Public Health to monitor the overall health budget System for mobilizing and monitoring financial flows for the whole sector Ensure appropriate financing of the sector Allocate 12% of the health budget Ensure financing of the various schemes, possibly subsidized (universal health insurance scheme and free schemes) Universal health insurance scheme subsidy plan Pooling resources/strategic purchasing Implement decentralization Municipal financing plan Optimize and align appropriations centrally Delegated appropriation targeting plan Allocation of appropriations Set up a strategic purchasing team Oversight/governance/ monitoring Alignment between planning and financing needs Results-based management (programme budget) Actual availability of financial resources in health facilities and flexibility in managing funds Review of provisions related to health facilities’ use of resources Source: Health Financing Strategy, Ministry of Health, 201710 11Process of transItIon to the Programme budget The transition in Burkina Faso lasted almost two decades. But, in 2017, Parliament institutionalized and adopted a programme budget. For the health sector, the years of preparation between 1998 and 2015 cultivated a favourable technical, legal and institutional environment. During that period, a programme budget was prepared for the MoH, to complement the input line budget. The objectives and programmes were aligned with the 2011–2020 National Health Development Plan. In 2018, under the leadership of a new minister, the MoH began to integrate budgetary programmes with a new vision for the sector that put prevention and universal access to services at the core. The MoH saw an opportunity to synchronize the sector’s priorities with the budget and took ownership of the reform. 2.1 PROGRAMME BUDGET: FROM PREPARATION TO INSTITUTIONALIZATION FOR ALL MINISTRIES (1998-2015) Burkina Faso introduced the concept of a programme budget in 1997.16 In 1998, the government chose six pilot ministries, including the MoH, to implement the system. The approach was extended in 2000 to all ministries and institutions. They were required to prepare a programme budget in addition to their line budgets. Those preparing these documents did not have access to suitable reference systems or frameworks. As a result, there was little consistency in their work. In 2005, the government started to frame and formalize the process, which was expedited in 2010. The Ministry of Finance (MoF) created governance entities with contacts in other ministries to implement closer oversight. The technical framework was developed to include benchmarks that offered guidance on preparing programme budgets, particularly for the six ministries that had taken part in the pilot project. From 2010 to 2016, the country entered a pre-institutionalization phase with the aim of meeting the deadlines set by WAEMU for a planned transition in 2017. The legislative and regulatory framework was updated between 2013 and 2016, as mentioned above (see section 1). Regulations were changed to comply with international recommendations to include accurate information on the number and structure of budgetary programmes with a maximum of seven programmes, 10 actions per programme, and 40 activities per action in each ministry.17 Support for ministries has been accelerated through training, along with adjustments to expenditure management and monitoring tools (See Box 1). In 2016, a presidential circular ordered a shift in the 2017 budget law. The programme budget became mandatory and would be the only budget presented by ministries. Parliament approved the law which set out 127 programmes and allocations for the 39 ministerial departments and institutions.XII XII The appropriations not allocated to programmes were divided into provisions, comprising a set of appropriations to cover expenditure that could not be directly linked to public policy objectives (Institutional Act, Art. 16). 2. PROCESS OF TRANSITION TO THE PROGRAMME BUDGET 12 BUDGETING IN HEALTH 2.2 THE MINISTRY OF HEALTH’S TRANSITION TO A PROGRAMME BUDGET: ALIGNMENT WITH NATIONAL HEALTH STRATEGIES The MoH budget was an input or line budget through the end of 2016. The budget was presented by type of expenditure, based on four main categories (headings) and then broken down by economic classification (article, section, paragraph) (see Table 6). The budget was detailed and was reported down to each item. For example, the heading “operating expenditures” included the article “purchase of goods and services” which was broken down to the section “supplies” then to the paragraph items “fuel, office supplies, maintenance products.” This structure had several disadvantages for those within the sector. Figure 1: History of the transition to the programme budget in Burkina Faso Source : Authors 1998: launch of the programme budget as an exercise for pilot ministries 2010-2015: strengthening the technical, legislative and institutional environment 2017: first official programme budget adopted by Parliament Activity 2016: Presidential memorandum officially establishing the programme budget in 2017 2000-2005: expanding the programme budget to all ministries INSTITUTIONALISATIONPREPARATION 2018: review of the programme budget content by the Ministry of Health 2020: complete review of the programme budget content planned for all the Ministries 13Process of transItIon to the Programme budget XIII (1) Policy document for the implementation of a programme budget in Burkina Faso, June 2010 (adopted by the Council of Ministers in June 2010); (2) “Programme budget implementation strategy” (approved by the government programme budget in June 2011 and adopted by the Council of Ministers in February 2012) supported by an action plan; (3) two methodology guides (a) to prepare the programme budget and (b) to monitor/evaluate the process in the ministries (adopted by the Council of Ministers in 2010 and 2011 respectively); (3) design of several mock-ups/outline for the ministerial programme budget document. XIV Order No. 2009-477/MEF/CAB of 29 December 2009 on the setting-up, roles, composition and running of the Steering Committee for the government programme budget and Order No. 2009-484/MEF/CAB of 29 December 2009 on the Unit to set up the government programme budget. XV Their aims were to provide guidance, to stimulate and supervise the process and finally, to lead the work to be performed on incorporating the WAEMU directives into the finance laws. The Steering Committee for the government programme budget and the Technical secretariat of the Steering Committee for the government programme budget were established by decree in September 2010. XVI Their roles were (i) to work with the MoF to contribute to the drafting or re-reading/transposition of the sector policy into a programme; (ii) to work with the MoF to lead the process of drafting and monitoring the implementation of their ministry or institution’s programme budget and (iii) to participate in the implementation of any activity contributing to the drafting of the government’s programme budget. XVII The Integrated Expenditure System (CID) has been adjusted to the programme approach. The budget planning module for the information system was therefore deployed to ensure the 2017 draft budget could be prepared, and that the system could include all the tables using the programme approach and in accordance with the LOLF. Technical guidance: production and gradual revision of standards and tools (guidance document for the implementation of the 2010 programme budget), programme- budget implementation strategy (2011), methodology guides (2010 and 2011),XIII outline, work on dividing public policies into budgetary programmes (2010-2011), setting out annual performance plans (from 2011 onwards), guide for programme-budget execution (2017) Governance: setting up governance of the reform involving finance and the sectors (budget planning reform committee (2008), steering committee for the implementation of the programme budget (from 2009)XIV with implementation teams in each ministryXV and the creation of ministerial technical units for the programme budgetXVI) Adapting the management tools: adapting financial information systems to the new approach (review of the Integrated Expenditure System – CID)XVII Capacity building: producing a capacity-building plan for stakeholders, including in the sectors (2013), with the exception of programme officers (from the Ministry of Health) appointed after the training. Capacity building activities targeted at the financial responsible officers, and not the operational arm of the reform (e.g., budgetary programme directors). Legal framework: Suitable legal and regulatory framework, including the transposition of WAEMU directives (2013-2016) Adoption of a presidential circular in 2016 for official transition to the programme budget in all ministries. Box 1: Key factors for programme budget institutionalization in Burkina Faso 14 BUDGETING IN HEALTH 1. Expenditures were broken down into categories unrelated to sectoral objectives and activities. 2. There was a lack of flexibility when reallocating between different items. XVIII 3. The reporting, although burdensome, was limited and did not provide information on the sector’s actual performance. The MoH had worked towards a programme budget since the pilot project in 1998. After more than a decade of trials, the line budget was converted to a programme budget in 2010. Those in charge of the Department of Studies and Planning (now the Directorate General of Sector Studies and Statistics) said the MoH saw the main advantage of the transition as being an “increased alignment between allocations and sector priorities.” The MoH’s initial proposal in 2010 was built around five programmes and 24 actions, associated with the strategic focus of the national health plan 2011–2020 and its 24 focus areas. Following discussions with the MoF, a consensus emerged around a smaller group of three programmes: access to services, health service delivery, and oversight. Budget pilot projects through 2016 would be developed on this basis and would be formalized starting in 2017 with modifications to the number of programmes and the drafting of actions (26 in 2017, 21 in 2018) and activities. The drafting of the 2011 programme budget demonstrated more consistency with the National Health Development Plan (PNDS), XVIII The absence of flexibility belongs more to an expenditure management issue than a purely budget formulation and presentation challenge. However, since expenditure management is often aligned on budget formulation, budgets that are formulated by inputs are generally associated with lack of flexibility in the use of resources. and a closer relationship between the sector’s needs and expenditures. A review of the strategic objectives of the PNDS and budgetary programmes reveals the commonalities (see Figure 2). The same model was used to prepare the MoH budgetary programmes in the years following 2011. Officials reviewed the PNDS 2016–2020 (second phase) and decided to mirror the plan’s new strategic objectives with the MoH’s three budgetary programmes. A new Minister of Health took up the post in February 2017. The budgetary programmes were redefined to correspond with his vision for the sector. The 2018 MoH organization chart aimed towards “a national health system that values prevention and makes the community-based approach to primary health care the foundation of Burkina Faso’s move towards universal health coverage”.XIX The proposed budgetary formulation changed to include: a national public health programme covering prevention, promotion and health security; a national programme of health care delivery and access to health products that targets curative care; and a national programme of governance of the health system. The proposed formulation was not adopted for the 2018 budget. Moreover, a formal review is not expected to take place before 2020 when the MoF has scheduled a review of all budgetary programmes (see Table 7). The MoH expected the official revision for the XIX Presentation by Prof. Nicolas Méda, Minister of Health: Vision, reorganization, priorities and response strategies, 2018 15Process of transItIon to the Programme budget project of finance law 2019 and proposed the following formulation: 1. Access/Purchase of health care 2. Provision of services/Public health 3. Governance/Stewardship This transitional approach was chosen to preserve the delivery of the operational content, which was identical to the 2018 budget. However, this created some confusion between the naming of the programmes and the outputs. For example, under the programme “Provision of services/ Public health”, most actions are a matter of provision, which was the former name of this programme. The MoH has committed to revisit the content of the programmes during the official revision in 2020–2021 and to propose a more coherent framework. 2.3 CHANGING ROLE OF STAKEHOLDERS IN THE REFORM The MoF managed the reform process with support from the International Monetary Fund (IMF). The transition to a programme budget was part of a broader reform to modernize public finance, which mainly affected the finance sector. The pressure from WAEMU to meet the 2017 deadline to introduce programme budgets encouraged major investment. Consequently, heads of state across the subregion were determined to push the reforms through. The MoF launched a dialogue with the six pilot ministries soon after they were chosen in 1998. For the MoH, the relationship between the budget and the national health plan was Table 6: Extract of the structure of the line budget, Ministry of Health (before 2017) Heading Chapter Article, section, paragraph Heading 3. Operating expenses Cabinet/General Secretariat/Departments Regional health directorates Health districts* Purchase of goods and services (article) – supplies (section) . fuel, office supplies, maintenance products, etc. (paragraph) . vaccines, specific supplies – expenditure on care/maintenance . building, vehicle, etc. – service provision . security costs, etc. . gas – others . meetings, travel, etc. . food, medicines, reagents, travel Heading 4. Current transfer expenditure Public establishments: university/regional hospitals National Centres Programmes/specific activities (diseases, free of charge/subsidies, national immunization days (NID), contributions to organizations, etc.) Interns/specialist doctors Operating Grants – subsidies to public institutions . salary, equipment, materials, medical care (public establishments, university/regional hospitals) – grants to beneficiary categories . support for activities (programme, specific actions) Other current transfers . contribution to organizations . internal allowances/bursaries Note: Health district: functioning of the district core team and provisions for medical centres with a surgical unit. Source: Budget 2016. 16 BUDGETING IN HEALTH critical, especially for planning. MoH officials, mainly those in the Department of Studies and Planning, increased their engagement in 2010 with the development of the PNDS 2011–2020. They took part in a number of joint committees led by the MoF as part of the dialogue. The Department of Studies and Planning was responsible for formulating the consolidated budget around three programmes. Its director was convinced of the necessity of budgetary reform and drove much of the progress. Many of those in the technical directorates and at the administrative levels in the sectors and districts did not share that commitment. The PNDS, the framework for formulating budgetary programmes, was meant to be developed in consultation with all stakeholders. However, much of that development did not come from the bottom up. A change in June 2018 in the organization chart of the MoH created two general directorates to administer the first two STRATEGIC GOALS OF THE PNDS 2011 BUDGETARY PROGRAMMES FOR HEALTH 2011-2018 STRATEGIC GOALS OF THE PNDS 2016 Figure 2: Mapping of 2011 PNDS objectives, 2011-2018 Ministry of Health budgetary programmes and 2016 PNDS objectives Increasing health financing and improving the affordability of health services Promoting health research Improving the management of the health information system Developing infrastructure, equipment and health products Promoting health and the fight against disease Developing human resources for health Improving health service delivery Developing leadership and governance in the health sector Access to health services Health service delivery Oversight and support for Ministry services Access to health services Health service delivery Oversight and support for Ministry services 17Process of transItIon to the Programme budget budgetary programmes (see Table 7). This structural change facilitated the transition.XX The Directorate General for Public Health would lead the public health budgetary programme, formerly “access to health services.” The Directorate General for Health Care and Health Products would lead the national care supply programme, formerly “delivery of health services”. The Directorate General for Sector Studies and Statistics (DGESS) would remain the lead for the programme on oversight and governance. These departments will require capacity building and support. They will need the skills and the technical tools to review the outlines and the content of their programmes: planning, prioritization, coordination, and definition of the performance monitoring framework. They will also need to be trained in the operational and financial management of a budgetary programme including planning, spending, monitoring, and reporting on performance. The MoH appointed programme managers in October 2017. They were expected XX MoH’s organization chart, May 2018 to become increasingly involved in the formulation of programme budgets and in their implementation from 2021 onwards.XXI Article 67 in the Institutional Act on Finance states that the authorization (“engagement”) may be delegated to the programme manager who “authorizes” the expenditure, with financial managers being part of each programme’s management team. The programme manager will be answerable for achieving results. The role of the Finance and Administration Department (DAF) will be modified and limited to the monitoring and financial reporting of the department’s expenditures. The DAF is expected to be replaced by financial officers integrated into each programme unit. XXI Initially planned for 2019, the scale plan was rescheduled in June 2018 to 2021. Table 7: Alignment between the new budgetary programmes and the Ministry of Health’s reorganization (2018) Formulation of budgetary programmes (until 2018) New formulation of budgetary programmes (as formulated by Ministry of Health); post-2018 Allocation to new Directorates (from 2018 onwards) Access to health services Public health Directorate General for Public Health Delivery of health services Supply and purchasing of health care Directorate General for Health Care and Health Products Oversight Oversight and governance Directorate General for Sector Studies and Statistics Source: Authors 18 BUDGETING IN HEALTH The structure of Burkina Faso’s MoH programme budget is built on three major programmes. The budget complies with legal requirements and with the goals of the PNDS 2011–2020. However, a more in-depth analysis reveals a need to review the drafting and shaping of certain actions and activities, to improve their relevance to the programme’s goals. While the programme budget has had an impact on the sector as a whole, it has specifically changed the management of specific interventions such as immunization and the fight against major epidemics, which are now part of broader budgetary programmes. 3.1 STRUCTURE OF THE MINISTRY OF HEALTH’S PROGRAMME BUDGET The MoH’s programme budget, adopted in 2017 and 2018, complies with legal requirements and follows a programme/ action/activity model, conforming to international recommendations (see Fig. 3). The programme level includes a public policy, a sector priority to which a goal is attached (e.g. access to quality health services). The action is associated with a set of measures (e.g. strengthening the infrastructure) to achieve the programme’s goal. In the MoH’s programme budget, an activity relates to more specific projects that have clearly identified costs (e.g. setting up a fund, purchasing vaccines). The number of programmes, actions and activities in the sector complies with legal requirements which set a maximum of seven programmes, 10 actions per programme, and 40 activities. In 2018, the MoH’s first two programmes consisted of six actions each. The third programme – oversight – consisted of nine. Each action is broken down into a variable number of activities (see Appendix 2). The first programme – access to health services – included 44 activities, excluding salaries. The second programme – delivery of health services – included 20 activities, excluding salaries. The third programme – oversight – included 39 activities. Beginning in 2018, the MTEF for health has followed the same format as the annual budget. The MTEF is structured in line with the three budgetary programmes and adheres to the strategic orientation of the PNDS. This would make it easier to anticipate the annual budgets for each programme. However, the decision to adopt a three-year programme budget has lessened the usefulness of the MTEF (see Box 2). 3. STRUCTURE AND CONTENT OF THE MINISTRY OF HEALTH’S BUDGETARY PROGRAMMES 19structure and content of the mInIstry of health’s budgetary Programmes 3.2 ANALYSIS OF THE CONTENT OF THE MINISTRY OF HEALTH’S BUDGETARY PROGRAMMES The MoH’s first two programmes meet the sector’s main objectives in the PNDS: (i) improving access to quality health services (access programme), and (ii) reducing morbidity and mortality through improved prevention, effective treatment and changes in behaviour (benefits programme). One formulation is directed towards output, the other towards outcomes. Yet the content in both relates to an overall system logic. By incorporating disease-specific work into broader programmes, this budget formulation enables a more coordinated approach in the system. The service delivery programme also presents an advantage for the sector in facilitating the establishment of a strategic purchasing function. Different actions or activities relate to a purchasing function without links being explicitly established: action 2 relates to funds for districts, health facilities, and other dedicated funds; action 3 to the provision of care; action 5 to funds dedicated to health promotion. The payment systems for these services have yet to be integrated into health financing reform. PROGRAMME 1 ACTION 1 ACTIVITY 1 ACTIVITY 2 ACTIVITY 3 ACTIVITY 4 ACTIVITY 5 ACTION 2 ACTION 3 ACTION 4 ACTION 5 ACTION 6 Figure 3: Structure of the Ministry of Health’s budgetary programmes in Burkina Faso Source: 2016 Budget 20 BUDGETING IN HEALTH The division between the first two programmes suggests that the first programme covers prevention and the second covers curative care, seeming to be a division of functions. However, this distinction is not as clear with respect to actions. The first programme – access – mainly includes actions that pertain to strengthening the health care offer including design, staff training, equipment, and health products. The second programme – services – actually includes several preventive actions such as disaster health management, health promotion, and community participation. The next programme review should clarify the outlines for each programme and integrate their formulation with the content. An analysis of each action also reveals certain weaknesses and suggests a need to review their definition and formulation, to improve their relevance. The programmes contain different types of actions. In the delivery of services programme, some actions refer to results (e.g. reduced endemic/epidemic disease morbidity and mortality). Others seem to refer more to activities (e.g. disaster health management). In the access programme, actions refer more to the linchpins or inputs in a health system, such as personnel, infrastructure, and equipment (see Table 8). The activities level appears to cover a more diverse group of projects, which creates problems with the formulation or indicates they are disconnected from the action they relate to. Some activities are consistent with the action and the programme; others appear reductive In 2001, the overall MTEF, the Medium-Term Budget Framework (MTBF), was introduced. It was structured by type of expenditure following the model used at the time in the annual budget. The first MTEF for the health sector was elaborated in 2005, following the strategic orientations of the National Health Development Plan (2001-2010). From 2011-2012, the health MTEF was formulated according to the PNDS 2011-2020’s eight strategic objectives and based on three scenarios, on the basis of Marginal Budgeting for Bottlenecks (MBB) cost estimates. The same still applies to the MTEF 2017-2020. It is considered an advocacy tool to mobilize more domestic but also external resources (external aid), by demonstrating the gap in funding between what is needed to achieve the strategic goals and the budgets allocated for the sector by the overall MTEF. Since it was decided to adopt a three-year programmes budget, the MTEF has ceased to be useful. The predictability that made the tool valuable in the annual state and sector budgets has become less important. The budget is now prepared for three years and adjusted each year according to macroeconomic forecasts and priorities. However, the health sector appears to want to retain the health MTEF in the future viewing it as a useful tool for its advocacy to mobilize resources, particularly external ones. From 2018 (MTEF 2018-2021), the structure of the health MTEF is expected to change and align with the structure of the Ministry of Health’s three budgetary programmes, on top of a PNDS divided into strategic goals and type of expenditure (based on three different scenarios). Box 2: Changes in the aggregate and sector MTEF structure in Burkina Faso 21structure and content of the mInIstry of health’s budgetary Programmes or misaligned with the programme’s goal. With respect to promoting health, the main action in 2017 is to “ensure the central and other authorities are working.” This does not appear to be focused on achieving the expected result (“improve hygiene, sanitation and behaviours conducive to good health”). Another example relates to the oversight programme; the “increased funding” action is linked to the programme budget formulation activity, which is certainly insufficient to increase funding, even though it can contribute to advocacy for more resources for the sector. XXII Some actions have been canceled between 2017 and 2018, like the action 05506. The action 05705, not present in 2017, has been reintroduced in 2018.••••••••••••••• Table 8: Ministry of Health’s programme budget’s programmes and actions (2018)* Programmes and actions 055 Access to health services 05501 Training of health personnel 05502 Constructing/rehabilitating health facilities 05503 Purchase and maintenance of sanitary equipment 05504 Improving the availability of quality health products 05505 Promoting systems to divide risks in the area of healthXXII 05507 Promoting traditional medicine and pharmacopoeia 056 Health service delivery 05601 Community participation 05602 Reducing morbidity and mortality associated with endemic/epidemic diseases 05603 Quality mother and child health services 05604 Disaster health management 05605 Health promotion 05606 Health product quality assurance 057 Oversight and support of Ministry of Health services 05701 Oversight, coordination and intersector collaboration of Ministry of Health actions 05702 Increase in health sector financing 05703 Management of financial and material resources 05704 Management of human resources 05705 Planning, monitoring and evaluation 05706 Building/rehabilitating and equipping administrative and educational infrastructure 05708 Health information 05709 Promoting health research 05710 Communication Source: Budget – expenditure, Ministry of Health, 2018 (CID). * Note: for the project of the finance law 2019, the proposed formulation is: 055 access to services/public health; 056 provision of health services/purchase; 057 oversight and support of services of the Ministry of Health/governance of health system 22 BUDGETING IN HEALTH 3.3 IMPLICATIONS OF THE REFORM FOR SPECIFIC HEALTH PROJECTS (IMMUNIZATION, HIV/AIDS, MALARIA, TUBERCULOSIS) Budgetary reform affected national and international partners including the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and Gavi, the Vaccine Alliance. The transition modified the budget item to which expenditure on disease-specific projects was charged. That changed where their work was reflected in the budget. Such interventions are listed under activities. The rationale is consistent with the PNDS. The budgetary change does not appear to have altered the level of funding for diseases or projects. Still, these partners will be monitoring developments. Prior to reform, budgetary allocations for immunization fell primarily under two main headings: purchasing vaccines and consumables, and support for national immunization days (NIDs). Now, these expenditures are divided between the first two budgetary programmes, access and delivery. Both operations can be found under activities. The purchase of vaccines is now charged as an activity in the access programme, under the action “improving the availability of quality health products”. The contribution to the financing of NIDs is included in the health services delivery programme, under the action “quality services for mother and child health” (see Table 9). The funding for each of the three major epidemics – HIV/ AIDS, tuberculosis, and malaria – is treated differently. The MoH plans some allocations for HIV/ AIDS-related projects. However, the National Multisector Programme to Combat HIV/ AIDS and Sexually-Transmitted Infections, a programme of the National Council to Combat HIV/AIDS and STDs placed under the auspices of the Presidency, provides most of the funding. Before 2017, spending on national resources was divided in the Presidency section into operating expenditure, a grant for the AIDS Solidarity Fund, and an entry under “project to support the implementation of the Strategic Framework for the fight against AIDS”. Afterwards, the allocations were grouped under a “Fight against HIV, AIDS and STDs” programme divided into three actions: 1. Preventing the transmission of HIV/AIDS and STDs; 2. Care, treatment, support and protection of those who are affected; and 3. Governance, funding of the response and strategic information management” (see Table 9). The MoH is responsible for a number of activities that respond to the aforementioned three actions, either on its own (e.g. promoting sexual and reproductive health) or alongside other ministries (e.g. promoting safer behaviour). Nevertheless, the budgetary allocation remains with the Presidency. Partners in the sector provide most of the financing, partly off-budget, in the fight against tuberculosis. For the state budget allocations through the MoH, the shift to a programme budget required funding dedicated to the prevention and fight against this disease, under the benefits programme. Previously, the allocations were essentially a contribution to the National and Regional Tuberculosis Control Centre and to the National Reference Laboratory for Tuberculosis, as well as a non-itemized allocation to run the National Tuberculosis Control Programme (under a Department of Health operating subsidy). After the transition, this earmarked funding has been charged to the benefits programme 23structure and content of the mInIstry of health’s budgetary Programmes under the action “reducing endemic/epidemic morbidity and mortality” and the activity “support for the national tuberculosis control centre”. Other unrestricted funding covers actions and activities related to the fight against tuberculosis including staffing, the running of diagnostic and treatment centres, the monitoring and dispensing of treatment was passed on to the health and welfare centres, as well as the payment of stipends to the community-based health workers who perform screening activities and provide support for treatment compliance. With regard to malaria, domestic funding is historically associated with two main activities: 1. an allocation to run the National Malaria Research and Training Centre – which is now part of the “steering and support for services” programme under the action “promotion of health research”; and 2. funding for preventive or curative activities related to a free health care programme (see Table 11). This free programme covers much of the funding for malaria-related activities and involves both preventive and curative activities. It covers children under 5 and pregnant women (preventive and curative activities) as well as postpartum women (curative activities) and is now included in the access programme. Since 2017, the activity “ensuring the implementation of the free health care strategy” was included in the action “promotion of mechanisms for sharing health risks” in the access programme. A second activity in the same programme that refers to the action “improving the availability of quality health products” was maintained to cover the purchase of malaria drugs, among other activities. These two budget items cover the authorities’ contribution to subsidizing free treatment in the fight against malaria. Table 9: Allocation of pre-reform and post-reform immunization expenditure Pre-reform (before 2017) Post-reform (2017 & 2018) Heading Programme Action Activity Heading 3. Operating expenses Chap. 65137. Department of prevention through immunization 621 62. Medical immunization products 621 69. Other specific supplies 055. Access to health services 05504. Improved availability of quality health products 0550401. Purchase vaccines and consumables Heading 4. Current transfers Chap. 61141. National Immunization Days 056. Health service delivery 05603. Quality health services for mother and child health 0560303. Organize national immunization days Source: Budgets 2016, 2017, 2018 (CID)18 24 BUDGETING IN HEALTH Table 10: Actions and activities posted under the Presidency’s “Fight against HIV, AIDS and STDs” budget plan Actions Activities Action 1: Preventing the transmission of HIV/AIDS and STDs Promoting safer behaviour through Information Education Communication/ Behaviour Change Communication and Sexual and Reproductive Health; promoting male and female condom use; promoting sexual and reproductive health and screening advice; eliminating mother-to-child transmission of HIV (+ projects financed externally) Action 2: Care, treatment, support and protection of infected and affected individuals Strengthen biological, medical-technical and clinical services; strengthen the drug supply system, including ARVs, reagents, consumables and equipment; increase the involvement of associations and communities in the continuum of care for people infected and affected by HIV; improve the financial support for PLHIV, people who are affected and specific groups in all sectors Action 3: Governance, financing the response and strategic information management Ensure the leadership is coordinated and maintained; strengthen the organizational and institutional capacities of facilities; ensure internal and external resources are mobilized; conduct epidemiological, sector behaviour and impact studies; improve the organization of the national monitoring and evaluation system; document and disseminate best practice in the fight against HIV and STDs Source: Budget – expenditure, Faso Presidency, 2018 (CID). Table 11: Budget allocation of malaria prevention and management expenditure in the programme budget (post-reform) Programmes Actions Activity Steering Promoting Health Research Ensuring the functioning of the National malaria research and training centre Access Promoting risk-sharing mechanisms Ensuring the implementation of the free health care strategy Improving the availability of health products Purchasing malaria drugs Source: 2017 & 2018 Budget 25fIrst effects of the reform (2017-2018): Progress and challenges The health sector’s transition to the programme budget in 2017 and 2018 brought a certain degree of flexibility to expenditures. Instances of this appeared in adjustments and reallocations during 2017 and 2018, between and within budgetary programmes. Expenditure practices also became more responsive to the sector’s changing needs. The programme budget performance monitoring framework offers more promise ahead. The tool provides users with information on the programmatic and financial performance of the sector which could inform future allocation decisions. 4.1 MOVING TOWARDS AN END TO ANNUAL DEFERRED BUDGETARY PROGRAMMES? The formulation of budgetary programmes evolved between 2017 and 2018. The adjustment of actions and activities made the programmes more coherent. For example, in 2017, the “functioning of central and regional directorates” activity was charged to the “health promotion” action in the “delivery of services” programme. In 2018, that activity was charged to the “oversight” programme. The “functioning of health districts and university/regional hospitals” activity was transferred from the “health promotion” action to the “reducing endemic/epidemic morbidity and mortality” action in the delivery of services programme. In the past, the budgeting process carried forward the same level of allocation for the same activities from one year to the next. Now, new activities can be included. Support for districts, regional health facilities and tertiary entities (university/regional hospitals) was added to the “reducing endemic/ epidemic morbidity and mortality” action. In 2017, no activity had been recorded under the action “community participation.” The “community- based health worker management” activity was added the following year. The 2017 budget for the management programme only provided for more targeted support for two local research facilities. Two activities were added in 2018, “payments to the health research support fund” and “ensuring that the National Institute of Public Health (INSP) is operational”. Authorities reviewed the formulation and the allocations every year. In 2017, the greatest share of allocations, 52% of the MoH budget, went to the access programme. In 2018, the greatest share, 47%, went to the benefits programme. The share for the oversight programme increased from 12% to 14% (see Fig. 4). The MoH global budget increased by 2% from 2017 to 2018. However, there were major variations between and within programmes and actions. The differences were mainly due to a transfer of staff costs from the access programme (-76%) to the benefits programme (+83%). Allocations for certain activities also deviated. Those for health promotion, quality services for mother and child health, and health product quality assurance varied by more than ±70% (see Appendix 3). 4. FIRST EFFECTS OF THE REFORM (2017–2018): PROGRESS AND CHALLENGES 26 BUDGETING IN HEALTH 4.2 TOWARDS MORE FLEXIBILITY IN SPENDING? Those who plan budgets now have more flexibility with the relaxing of some ex ante controls to authorize expenditures. In the past, they made commitments for their programmes and had to justify them down to the paragraph. Now, they are only required to justify down to the section level. Input- based logic is still present in the authorization process. This flexibility is reflected in varying levels of implementation between and within programmes. In 2017, the access program achieved an implementation rate of 115%. The services programme achieved a rate of 66%. The implementation level for all three programmes reached 93% (see Table 12). Aside from personnel, fungibility provides the flexibility for expenditure items within the same programme to vary up or down with no preset limit. The level of implementation of the actions within programmes varies, from 33% to 175%. Variations in the implementation of activities could be due to the inconsistency of carrying out those activities. However, such variation could also reflect an increased flexibility in financial management and an approach that is more responsive to the sector’s needs. A common pitfall in budgeting is to manage health personnel costs outside of programmes 51,8% 35,8% 12,4% Budget 2017 37,6% 47,5% 14,9% Budget 2018 055 Access to health services 056 Health service delivery 057 Oversight and support Figure 4: Distribution of budget appropriations by programme in 2017 and 2018, Ministry of Health Source : Ministère de la Santé, 2017 et 2018 27fIrst effects of the reform (2017-2018): Progress and challenges within a specific staff line or lines. However, such costs in the MoH are charged to each budgetary programme.XXIII The budget includes three blocks for remuneration (called the balance) which are connected to the first action in each programme, with no specific relation to the content of the action. This could provide the advantage of including a major cost driver – 58% of expenditures within the benefits programme in 2018, for example – as part of a true model of programme efficiency. The allocations for staff costs in 2017 differ significantly from the implementation. This implies estimates were unreliable. Implementation in the access programme is much higher than stated in the initial budget, at 190% of the revised allocations. Implementation in the services programme was 25% of allocations. In 2018, the MoH doubled allocations in a mass transfer to the “delivery” programme, covering 70% of salaries. Allocations for the “access” programme were reduced to 30%. The Ministry of the Economy, Finance and Development maintains responsibility for salaries. So dividing staff costs across the XXIII Personnel expenditure at tertiary level (university/regional hospital) is accounted for in transfers to these bodies and is therefore not included in the remuneration expenditure. MoH’s three programmes appears to be an artificial exercise. The entries are not, in fact, linked to the action they have been logged under. Salaries in the access programme appear under “training health staff”. Salaries in the second programme appear under “community participation”. These lines are retroactive entries in the monitoring of expenditures. The MoH has little flexibility in adjusting payroll if it is to meet the goals of each programme (see section 1.2). Until it can manage remuneration more effectively, it will be limited in its ability to move towards more strategic purchasing of services and more efficient spending. 4.3 TOWARDS FINANCIAL ACCOUNTABILITY THAT IS OF BENEFIT TO THE SECTOR? A programme budget works in concert with a performance monitoring framework (PMF)21 that makes it possible to link allocated resources with changes in a sector’s performance, a method of appraisal that had Table 12: Implementation of the health budgetary programmes (2017) Initial provision (thousands CFA francs) Revised provision (thousands CFA francs) Settlement (thousands CFA francs) Implementation (%) Access to health services 121,287,749 101,457,294 117,515,245 115.8% Provision of health services 71,585,283 70,051,757 46,313,277 66.1% Steering and support 23,193,257 24,210,695 19,069,684 78.8% Total 216,066,289 195,719,746 182,898,206 93.4% Source: CID, 2017 28 BUDGETING IN HEALTH Table 13: Extract from the Ministry of Health programme budget’s Performance Monitoring (2018-2020) Strategic objectives Indicators Reference Targets Responsible directorate Unit Year Value 2018 2019 2020 Programme 056 Health service delivery Reduce morbidity and mortality for better prevention, effective treatment and a change in behaviour Maternal mortality rate RATIO 2016 341 243 243 243 DGESS Mortality rate for children under five RATIO 2016 ND 62,75 62,75 62,75 DGESS Action 05601 Community participation Promote community-based action in the area of health Number of NGOs who have a performance contract with the Ministry of Health NO. 2016 252 252 252 252 DGS Number of villages covered by the OBC-E NO. 2016 8000 8000 8000 8000 DGS Action 05602 Reducing morbidity and mortality related to endemic/epidemic diseases Promote community-based action in health1 New contacts per inhabitant and year in the primary health care facilities (CM and CSPS) NO. 2016 1,02 1,3 1,4 1,5 DGESS Bed occupancy rate in the hospitals % 2016 50,5 60 65 70 DGS Action 05603 Quality service offer for mother and child Improve mother and child health Rate of assisted deliveries % 2016 80,9 >=87 >=90 >=90 DGESS Rate of caesarean sections among assisted births % 2016 >=3.5 >=3.8 >=3.9 >=4 DGESS Immunisation rate of pentavalent vaccine among children % 2016 103 100 100 100 DGESS Action 05604 Disaster health management Improve disaster health management Coverage rate for disaster victims % 2016 NA 80 80 80 DGS Proportion of hospitals with a response plan <plan blanc> % 2016 100 100 100 100 DGS 1 The repetition of actions between 05602 and 05601 is provided in the original document. DGESS: Directorate general of sector studies and statistics DGS: Directorate general of health Source: Budget 201819 29fIrst effects of the reform (2017-2018): Progress and challenges not previously existed.XXIV A PMF is defined according to the programme, not by inputs. The MoH framework provides information on achieving the goals of each of its first two budgetary programmes, namely “improving access to quality health services” and “reducing morbidity and mortality through better prevention, effective care and changes in behaviour” (see section 3.2). The PMF has the advantage of being managed at the levels of programme and action. The programme manager is expected to report to action level and not to a lower level (activities). That gives them some autonomy in the implementation of activities. They will not be judged on whether or not an activity is complete, but on whether a particular result has been achieved, depending on the resources that have been allocated (see Table 13). XXIV Performance monitoring under the PNDS does not link the achievement of the goals directly to the expenditure to achieve these same goals. The volume of performance data reported in Burkina Faso is moderate in comparison to international standards.XXV Still, the performance framework would need some adjustments if it is to properly measure the achievement of the expected results. The indicators comply with the PNDS but do not follow a logical framework between results and inputs. If the MoH adjusted the framework, it would have a useful tool to evaluate the operational and financial performance of the sector and inform decisions on allocations. Annual performance monitoring would enhance these benefits and the programme budget would make a more significant contribution to the sector. XXV One sole outcome indicator is provided, and a maximum of three outcome indicators per action are suggested. 30 BUDGETING IN HEALTH SUMMARY OF PROGRESS, CHALLENGES AND RECOMMENDATIONS Summary of progress and challenges in the implementation of the health programme budget in Burkina Faso Progress Challenges Budget planning Aligning budget formulation with PNDS (2011–2020) priorities Need to update the outlines and content of budgetary programmes in light of new policy directions for the sector Year-to-year adjustments between and within programmes Usefulness of the MTEF given that the budget is defined for three years Harmonizing departmental organization and budgetary programmes to facilitate implementation and accountability Delay in appointing managers following the reorganization of the MoH, which impeded budget planning before 2019 “Responsibility chain” was redefined Implementing expenditure Financial management tools adjusted to programme budgeting Ineffective transferring of expenditure authorizing to programme managers Effective implementation of the principle of decentralized authorizing at the benefit of the minister Artificially including staff remuneration with programme formulation Effective implementation of the fungibility principle at programme level Fungibility justified on the basis of inputs Performance monitoring and accountability Annual performance monitoring at programme and action level Relevance and consistency of performance framework to be improved Technical capacity and ownership Understanding, ownership and leadership in the design of programme budget by MoH Lack of ownership by newly appointed programme managers Strong DAF teams formed Operational teams not complete and not trained to effectively manage budgetary programmes 31summary of Progress, challenges and recommendatIons RECOMMENDATIONS The following roadmap was defined and reviewed by participants in the MoH/WHO seminar on the programme budget in health in Ouagadougou on 11–12 July 2018. Formulation of budgetary programmes in health: Reformulate the name, content, and outline of budgetary programmes according to the new orientations of the sector Use the results of the annual reports on performance to inform the budgetary allocations for the following year Ensure the coherence of the performance monitoring framework with the new budgetary programmes Clarify the purpose of the sectoral MTEF (information and advocacy) and the three-year budget as the primary tools for budgetary programming Implementation and monitoring of the budgetary reform in health: Take part and use the results reform review to integrate lessons for a rapid implementation of the reform in 2020- 2021 Formulate and improve communication and coordination mechanisms between and within the budgetary programme teams, at the financial and operational levels Prepare for the effective transition of the financial management of programmes including the integration of those in charge of finances within the programmes Coordinate the implementation of the budget reform with the reform of health financing, specifically related to the universal health insurance scheme and other measures concurring with the more strategic purchase of health services Ensure coherence between the institutionalization of budget reform and the implementation of decentralization (in particular pending transfers of skills to the regions) Make progress with the MoF and the civil service on allocating the remuneration of health personnel at the programme level Implementation of teams and capacity building: Finalize the assignment, organization and operation of the different entities and the new directorates according to the 2018 MoH organization chart Strengthen programme managers’ capacities to prepare and manage budgetary programmes through training Make the teams of programme managers operational by including trained financial managers in each programme. 32 BUDGETING IN HEALTH BIBLIOGRAPHY 1. Barroy H, Dale E, Sparkes S, Kutzin J. Budget matters for health: key formulation and classification issues, Policy brief N°4, World Health Organization, 2018 (http://apps.who. int/iris/bitstream/handle/10665/273000/WHO-HIS-HGF-PolicyBrief-18.1-eng.pdf?ua=1) 2. World Health Organisation. Budgeting in health, Genève : Organisation mondiale de la Santé (http://www.who.int/health_financing/topics/budgeting-in-health/en/) 3. Union économique et monétaire ouest-africaine. Guide didactique de la Directive n°06/2009/ CM/UEMOA portant lois de finances au sein de l’UEMOA. Dakar : UEMOA, 2009 (http:// www.droit-afrique.com/upload/doc/uemoa/UEMOA-Directive-2009-06-lois-de-finances. pdf, consulté le 15 mai 2018) 4. Union économique et monétaire ouest-africaine. Rapport de mise en oeuvre du cadre harmonisé des finances publiques, 2e réunion de l’Observatoire des Finances Publiques. UEMOA, Lomé, 7-11 novembre 2016. 5. Secrétariat général du gouvernement et du Conseil des ministres. www.legiburkina.bf 6. Lawson A., Chiche M., Ouedraogo I. Évaluation de la réforme de la gestion des finances publiques au Burkina Faso 2001–2010, Danida, Rapport d’étude de cas pays – version finale. Danish International Development Assistance (Danida), Swedish International Development Cooperation Agency (Sida). Stockholm, 2012 (https://www.oecd.org/fr/pays/burkinafaso/ burkina_francais.pdf, consulté le 15 mai 2018) 7. Ministère de l’Économie et des Finances. Politique sectorielle 2011-2020 de l’économie et des finances – POSEF 2001-2010. Ouagadougou, 2011. (http://www.sips.gov.bf/img_tmp_ fichiers/MEF-PS-1.pdf, consulté le 15 mai 2018) 8. Ministère de la Santé. Stratégie nationale de financement de la santé pour la couverture santé universelle, 2017-2030. Ouagadougou. Octobre 2017 9. Ministère de la santé. Comptes nationaux de la santé, 2015 10. Kelley A.et al. Une vue d’hélicoptère : cartographie des régimes de financement de la santé dans 12 pays d’Afrique Francophone. Communauté de Pratique Accès financier aux Services de Santé et Communauté de Pratique Financement Basé sur la Performance, 2014 (http://docplayer.fr/amp/76977257-Une-vue-d-helicoptere-cartographie-des-regimes- definancement-de-la-sante-dans-12-pays-d-afrique-francophone.html, consulté le 15 mai 2018) 33summary of Progress, challenges and recommendatIons 11. ASMADE. Inventaire des mutuelles sociales dans la perspective de l’assurance maladie universelle au Burkina Faso. Ouagadougou, 2011 (http://ongasmade.org/new/images/PDF/ ouvrages/INVENTAIREDESMUTUELLESSOCIALES2011VF.pdf, consulté le 15 mai 2018) 12. Étude sur le système mixte de modalités d’achat et de paiement des services de santé : Cas du Burkina Faso. Genève, Organisation mondiale de la santé, 2017. 13. Code général des collectivités territoriales 2004 14. Décret 2009-109/PRES/PM/MFPRE/MATD/MEF du 3 mars 2009 portant transfert des compétences et ressources de l’État aux communes dans le domaine de la santé 15. Décret 2014/920/PM/PATD/MDS/MEF/MFPTSS du 10 octobre 2014 portant transfert des compétences et ressources de l’État aux régions dans le domaine de la santé 16. Circulaire budgétaire n°97-054/PRES du 26 mai 1997 pour la préparation de la loi de finances-gestion 1998 17. Décret N° 2016-600 sur la nomenclature budgétaire 18. Écran d’engagement du Circuit informatisé de la dépense (CID) à la date du 14 février 2018 19. Ministère de la Santé. Cadre de performance des programmes budgétaires du Ministère de la santé, 2018-2020. 34 BUDGETING IN HEALTH LIST OF OFFICIAL DOCUMENTS REVIEWED Public financial management and programme budget documents DANIDA, Evaluation of Public Financial Management Reform in Burkina Faso 2001-2010, Country case study report – Final version, June 2012 Ministry of the Economy and Finance, Detailed report of the medium-term fiscal framework 2016-2018, April 2015 Ministry of the Economy and Finance, Economic and financial sector policy 2011-2020, April 2011 Ministry of the Economy and Finance, Guidance document for the implementation of the programme budget in Burkina Faso, June 2010 Ministry of the Economy and Finance, Methodology guide for drafting the government’s programme budget, Ministry of the Economy, Finance and Development, Forecast of overall expenditure by type 2018-2020 Ministry of the Economy, Finance and Development, Multiyear budget and economic planning document 2018-2020, April 2017 Ministry of the Economy, Finance and Development, Proposed staff costs 2017-2019, Baseline scenario, Ministry of the Economy, Finance and Development, Programme budget implementation guide, Public expenditure component, April 2017 Ministry of Health, Medium-Term Expenditure Framework 2016-2018, 12th edition, December 2015 Ministry of Health, Medium-Term Expenditure Framework 2017-2019, 13th edition, December 2016 Ministry of Health, Medium-Term Expenditure Framework 2018-2020, 14th edition, December 2017 Ministry of Health, Ministry of Health programme budget 2013-2015, September 2012 35bIblIograPhy Ministry of Health, Ministry of Health programme budget 2015-2017, Final Version, September 2014 Ministry of Health, Ministry of Health programme budget 2016-2018, draft, June 2015 Ministry of Health, Ministry of Health programme budget 2017-2019, October 2016 Ministry of Health, Ministry of Health programme budget 2018-2020 Ministry of Health, Settlement bond No. 2017-2140-6 of 23 October 2017 Public financial management and statistics support programme, Mid-term evaluation of Economic and financial sector policy 2011-2020, 2015 West African Economic and Monetary Union, Press statement of the ordinary session of the Council of Ministers of the Union, Dakar, 31 March 2017 Health-specific documents National assembly, Summary report of the parliamentary inquiry into the health system in Burkina Faso 2006-2016, July 2017 Ministry of Health, Classification of National Health Development Plan 2011-2020 activities (Phase II), May 2017 Ministry of Health, Draft national health sector policy, August 2017 Ministry of Health, Guide for drawing up annual action plans for central and technical directorates, December 2017 Ministry of Health, Health sector policy support project (PAPS/UE-Lot2), Draft study report on the mission, role and functioning of the health district in the light of current reforms, June 2017 Ministry of Health, Joint assessment of the National Health Development Plan in Burkina Faso 2011-2020, Final assessment report, September 2016 Ministry of Public Service, Labour and Social Welfare, Classification and tariffs of professional health procedures in public health facilities and hospital establishments in Burkina Faso, draft report, July 2017 Ministry of Health, Mid-term evaluation report of the PNDS 2011-2020 Burkina Faso, Ministry of Health, Mid-2017 Performance sector report, National Plan for Economic and Social Development, Health planning sector, August 2017 36 BUDGETING IN HEALTH Ministry of Health, Monitoring and Evaluation Plan of the Malaria Strategic Plan 2016-2020, January 2017 Ministry of Health, National Health Development Plan 2011-2020, 2011 Ministry of Health, National Health Development Plan PNDS 2011-2020, Phase 2016-2020, December 2016 Ministry of Health, National health financing strategy for universal health coverage 2017-2030, October 2017 Ministry of Health, National plan for managing insecticide resistance by malaria vectors 2016- 2020, December 2018 Ministry of Health, National Strategic Plan for Malaria Control 2016-2020, October 2016 Ministry of Health, National strategy for the implementation of free health care for women and children under five, December 2017 Ministry of Health, Planning guidelines 2018, January 2018 Ministry of Health, PNDS Monitoring and Evaluation Plan 2011-2020, January 2012 Ministry of Health, Sector performance report 2016, Health planning sector, March 2017 Ministry of Health, Strategic Plan for Tuberculosis Control 2018-2022, June 2017 General documents and working instruments Burkina Faso, National Plan for Economic and Social Development 2016-2020, July 2016 Computerized expenditure system, Budget implementation, State funding, Fiscal year 2017, on 30 February 2018 Computerized expenditure system, Budget implementation, State funding, Fiscal year 2018, on 30 February 2018 Computerized expenditure system (CID) draft settlement screen Computerized expenditure flow, Table of cost of activities by action and programme (thousands of FCFA) Integrated financial management system (CID) validation screen on 14 February 2018 37bIblIograPhy Ministry of the Economy, Finance and Development, Basic structure for drafting programme budget documents Ministry of Health, Criteria and key aspects for allocating state budget funds, management 2018 Ministry of Health, Key aspects and criteria for allocating the 2014 state budget Ministry of Health, Report on the workshop to review the criteria and keys for allocating state budget funds, May 2014 Ministry of Health, Total Ministry of Health expenditure by action, 31 December 2017 Ministry of Health, Total Ministry of Health expenditure by action, 31 January 2018 Ministry of Health, Total Ministry of Health expenditure by programme and type, 31 December 2017 Ministry of Health, Total Ministry of Health expenditure by programme and type, 31 January 2018 Ministry of Health, Transition Matrix Programme budget, National health development policy, July 2017 Ministry of Regional Administration and Decentralization, Validation form No. 2018-0913-9 of 05 February 2018 WAEMU, Training guide for Directive No. 06/2009/CM/WAEMU on the Finance Act in WAEMU WAEMU, Report on the implementation of the harmonized framework for public finances, second meeting of the Public finance monitoring unit, Lomé, 7-11 November 2016 Regulatory and institutional texts Act No. 040-2016/AN of 15 December 2016 on the Finance Act for the implementation of the state budget, 2017 financial year Act No. 052-2017/AN of 27 November 2017 on the Finance Act for the implementation of the state budget, 2018 financial year Act No. 008-2013/AN of 23 April 2013 on the general code of transparency in public financial management in Burkina Faso Act No. 039-2016/AN of 02 December 2016 on the general regulation of public procurement 38 BUDGETING IN HEALTH Act No. 073-2015/CNT of 06 November 2015 on the Institutional act on finance laws (LOLF) in Burkina Faso Circular No. 2016-0001/PRES of 22 June 2016 on the drafting of the government budget, financial year 2017 Circular No. 2017-0386/MINEFID/CAB on the role of the parties involved in the implementation of the programme budget in the transitional phase of the enforcement of the LOLF, February 2017 Decree No. appointing budget plan officers representing the Ministry of Health, Council of Ministers of 18 October 2017 Decree No. 2016- 601/PRES/PM/MINEFID of 08 July 2016 on the conceptual framework of state accounting Decree No. 2016-311/PRE/PM/MS/MATDSI/MINEFID of 29 April 2016 on free health care for women and children under five living in Burkina Faso Decree No. 2016-598/PRES/PM/MIINEFID of 08 July 2016 on general regulations on public accounting Decree No. 2017-0004/PRES/PM/MlNEFID of 12 January 2017 on the establishment, powers, organization and functioning of the National Plan for Economic and Social Development monitoring and evaluation system Decree No. 2016-753/PRES/PM/MS of 16 August 2016 on the organization of the Ministry of Health Decree No. 2018-0093/PRE/PM/MS of 15 February 2018 on the organization of the Ministry of Health Decree No. 2017-0049/PRES/PM/MINEFID of 1 February 2017 on procedures for awarding, executing and regulating public procurement and the delegation of public services Decree No. 2014-920/PRES/PM/MATD/MS/MEF/MFPTSS of 10 October 2014 on the transfer of powers and resources in health and hygiene from the State to the regions Decree No. 2009-108/PRES/PM/MATD/MS/MEF/MFPRE of 3 March 2009 on the transfer of powers and resources in the health sector from the State to municipalities Directive No. 06/2009/CM/WAEMU of 26 June 2009 on finance laws in WAEMU Directive No. 01/2009/CM/WAEMU of 27 March 2009 on the code of transparency in the management of public finances in WAEMU 39bIblIograPhy Directive No. 07/2009/CM/WAEMU of 26 June 2009 on the general regulation on public accounting in WAEMU Directive No. 08/2009/CM/WAEMU of 26 June 2009 on the government budget classification in WAEMU Directive No. 09/2009/CM/WAEMU of 26 June 2009 on the government chart of accounts (PCE) in WAEMU Interministerial order No. 2017-018/MINEFID/MATDS/MS of 12 January 2017 on the allocation of two billion two hundred and eighty-four million one hundred and forty-seven thousand three hundred and eighty-two (2,284,147,382) CFA francs representing the financial resources transferred to the municipalities for the powers transferred in the area of health with respect to recurring charges pertaining to the State budget, financial year 2017 Interministerial order No. 2017-020/MINEFID/MATDSI/MS of 24 January 2017 on the allocation of two billion nine hundred and ninety-nine million nine hundred and eighty-eight thousand and forty-five (2 999 988 045) CFA francs representing the financial resources transferred to the municipalities to support the powers transferred in the area of health with respect to investments pertaining to the State budget, financial year 2017 Joint order No. 2016-608/MS/MINEFID of 7 November 2016 on determining eligible expenditure in the context of free health care for women and children under the age of five in Burkina Faso Letter No. 2017-0386/MINEFID/CAB of 14 February 2017: role of the parties involved in the implementation of the programme budget during the transitional phase of the enforcement of the LOLF Order No. 2017-1244/MS/SG/DAF of 08 September 2017 amending the budget appropriations of programme 056 of the Ministry of Health, financial year 2017 Order No. 10/2009/CM/WAEMU of 26 June 2009 on the government financial operations table in WAEMU 40 BUDGETING IN HEALTH APPENDIX 1: BUDGET-PLANNING PROCESS SINCE THE ADOPTION OF THE PROGRAMME BUDGET The process and various parties involved in the ministerial budget planning are as follows: Presidential circular launching the budget-planning process setting out the assumptions and budget framework, as well as the general and sector-specific priorities and the strategic budgetary choices adopted by the authorities (outline of the BP attached). Send the ministries’ and institutions’ reference allocations to the departments, by type of expenditure, to implement the programmes they are responsible for, as specified in the Multiyear budget and economic planning document drawn up by the Directorate general for the budget of the Ministry of Finance (general MTEF). Minister of Health sets up the Budget planning committee and subcommittees, according to the type of expenditure. This committee sends the various entities in the Ministry (Directorates, regional/ district health directorates, university/ regional hospitals, establishments, etc.): (1) the provisions granted to each of them according to the intrasector distribution and total amounts allocated to operating and/or transfer appropriations; (2) a request framework to ascertain the financial needs/cost of “activities” for each, according to the economic classification of the expenditure. The committee selects and consolidates the various requests sent by the entities and incorporates them in the actions and programmes; specific work on staff costs and investment according to the information requested by the Directorate general for the budget; validation by the ministerial authorities. DAF planning department includes all the information and tables needed to prepare the Ministry of Health draft programme budget in the CID (programming module), including the programmes’ performance framework; finalize the sector “Programme budget” document. Discussion of the ministerial budget proposal (summary table and “Programme budget” document) at a Budget Committee with the Ministry of the Economy, Finance and Development before inclusion in the draft budget/ government Finance Law, which will be presented and validated in the Council of Ministers before being submitted to the National Assembly (Draft Finance bill and all the documents prescribed by the LOLF including the ministerial “Programme budget” documents). APPENDIXES 41aPPendIxes APPENDIX 2: LIST OF THE MINISTRY OF HEALTH’S PROGRAMME BUDGET’S ACTIONS AND ACTIVITIES Programmes, actions and activities 055 Access to health services 05501 Training of health personnel Ensure support for students at the end of their studies, interns, doctors undergoing specialized training; ensure the continuing training of staff; ensure the National School of Public Health continues to provide training + 2018 Ensure a single examination is organized 05502 Construction/rehabilitation of health infrastructure and 05503 Purchase and maintenance of health equipment Various investment projects 05504 Improving the availability of quality health products Purchase vaccines and consumables; purchase drugs; purchase therapeutic foods/micronutrients (consolidation of social safety net); purchase health products (reagents, malaria drugs, medical and blood consumables – social safety net); support dialysis unit and running of the blood transfusion centre 05505 Promoting health risk-sharing schemes Ensure the implementation of the free health care strategy 05507 Promoting traditional medicine and pharmacopoeia Organize the African Traditional Medicine Days 056 Health service delivery 05601 Community participation 2017: (no activity) 2018: Care for community-based health workers (CBHW) 05602 Reducing morbidity and mortality associated with endemic/epidemic diseases 2017: Specific funds (fight against neglected tropical diseases, response to epidemics, national disease control funds, funds to support the vulnerable persons programme, etc.); Specialist centres (tuberculosis, blindness) 2018: Specific funds (fight against neglected tropical diseases, response to epidemics, national disease control funds, support funds for the vulnerable persons programme, etc.); districts (monitor the running of the health districts); university, regional and district hospitals (monitor the running* of university and regional hospitals); specialist centres (tuberculosis, blindness); HIV/AIDS sectoral programme 05603 Quality mother and child health services Purchase contraceptive products; Organize National Immunization Days; + 2017: HIV/AIDS sector programme  05604 Disaster health management Supply the national fund for the fight against epidemics 05605 Health promotion 2017: Monitor the running of central administrations, regional health directorates (monitor the running of decentralized bodies); Districts (monitor the running of decentralized bodies); university, regional and district hospitals (monitor the running* of public health establishments); management of CHBW; health promotion in the towns (ensure commitments to the global fund to tackle certain diseases) 2018: Health promotion in towns (support health promotion activities in towns); 42 BUDGETING IN HEALTH Programmes, actions et activités 057 Department of health services’ oversight and support 05701 Ministry of Health oversight, coordination and intersector collaboration Contribution to international organizations 2018: Functioning of central administrations; regional health directorates (functioning of regional health directorates); Contribution to international organizations 05702 Increase in health sector financing Drafting the Ministry of Health programme budget 05703 Management of financial and material resources Cover the expenses of medical evacuation (transport and hospitalization expenses); cover the project’s expenses, water/electricity, telephone, etc. 05704 Management of human resources Support the functioning of the professional bodies; + 2017, Ensure the organization of single screening 05705 Planning, monitoring and evaluation 2017: Action not selected 2018: Develop planning guidelines, hold National Plan for Economic and Social Development sector dialogue framework sessions, update health card, 05706 Building/rehabilitating and equipping administrative and educational infrastructure Various activities: office furniture equipment, computer equipment, building district management team offices, etc. 05708 Health information Support the running of the drug information and documentation centre + 2018: Develop national health accounts 05709 Health Research Promotion Support operations at the National malaria research and training centre, the Muraz centre, the Nouna health research centre + 2018: Supply the fund to support health research; Ensure the operation of the National institute of public health (INSP) 05710 Communication Support Ministry of Health communication APPENDIX 2: continued 43aPPendIxes APPENDIX 3: VARIATION IN ALLOCATIONS BY PROGRAMME AND ACTION BETWEEN 2017 AND 2018 By programme and action 2017 2018 74.566.207 055 Access to health services Revised provisions 2017 Initial provisions 2018 Variation 2018/2017 (%) 05501 Training of health personnel 33.798.558 12.232.982 -64% per month 28.343.084 6.686.644 -76% 05502 Construction/rehabilitation of health facilities 20.010.259 17.800.429 -11% 05503 Purchase and maintenance of health facilities 20.089.074 18.195.826 -9% 05504 Improving the availability of quality health products 11.329.863 10.748.334 -5% 05505 Promoting health risk sharing schemes 16.219.240 16.125.742 -1% 05507 Promoting traditional medicine and pharmacopoeia 10.300 20.000 94% Total Programme 055 101.457.294 75.123.313 -26% 056 Health service delivery 05601 Community participation 28.372.483 55.191.939 95% per month 28.331.267 51.813.779 83% 05602 Reducing morbidity and mortality related to endemic/epidemic diseases 3.770.526 34.269.202 05603 Provision of quality maternal and child health services 648.617 1.550.000 139% 05604 Disaster health management 51.627 50.000 -3% 05605 Health promotion 36.598.090 2.359.529 -94% 05606 Health product quality assurance 610.414 1.566.894 157% Total Programme 056 70.051.757 94.987.564 36% 057 Department of health services’ oversight and support 05701 Ministry of Health oversight, coordination and intersector collaboration 13.571.042 17.623.612 30% per month 13.435.423 16.065.784 20% 05702 Increase in health sector financing 20.033 25.000 25% 05703 Management of financial and material resources 7.207.967 6.703.608 -7% 05704 Management of human resources 461.453 1.530.476 232% 05705 Planning, monitoring and evaluation – 43.000 0% 05706 Building/rehabilitating and equipping administrative and educational infrastructure 1.942.534 2.550.389 31% 05708 Health information 10.033 15.000 50% 05709 Health Research Promotion 879.246 1.162.702 32% 05710 Communication 118.387 30.000 -75% Total Programme 057 24.210.695 29.683.787 23% GENERAL TOTAL 195.719.746 199.794.664 2,1% Source : CID ; pour l’année 2017, état de situation tiré à partir du CID au niveau de la DAF/MS (service de l’execution budgétaire) Notes : 1. Dotations révisées : elles tiennent comptepour 2017, des deux Lois de finances rectificatives, des régulations/blocages instaurés par le MINEFID intégrés dans le CID, des modifications des crédits budgétaires au sein des programmes (dans le cadre de la fongibilité des crédits). 2. Investissement : crédits de paiement 44 BUDGETING IN HEALTH APPENDIX 4: MINISTRY OF HEALTH’S BUDGETARY PROGRAMMES PERFORMANCE FRAMEWORK 2018-2020 Objectifs stratégique/ opérationnel Indicateurs d’impact /d’effet Référence Cibles Responsable Unité Année Valeur 2018 2019 2020 Programme 055 Accès aux sevices de santé Améliorer l’accès des populations aux services de santé de qualité Rayon moyen d’action théorique KM 2015 6,8 6,1 5,9 DGESS Pourcentage de la population vivant à moins de 5 km d’une formation sanitaire (FS) KM 2015 58,1 60 62,5 DGESS Action 05501 Formation du personnel de santé Produire des ressources humaines suffissantes et de qualité pour la santé Ration population / médecins RATIO 2016 15836 14000 13000 DRH Ratio population / IDE RATIO 2016 4108 <4000 <4000 <4000 DRH Ratio population / SFE 7778 INF7000 INF7000 INF7000 DRH Action 05502 Construction/Rehabilitation d’infrastructures sanitaires Développer les infrastructures sanitaires Pourcentage des formtions sanitaires répondant aux normes en infrastru RATIO 2016 NA 85 90 95 DGESS Action 05503 Acquisition et maintenance des équipements sanitaires Développer les équipements sanitaires et leur maintenance Pourcentage des formations sanitaires fonctionnelles selon les normes en équipements sanitaires % 2016 ND 65 70 75 DGESS Action 05504 Amélioration de la disponibilité des produits de santé de qualité Renforcer le circuit d’approvision- nement et de distribution des Produits de santé tie qualité Pourcentage des DMEG n’ayant pas connu de rupture des 20 molécules traceurs % 2016 28 DGESS Taux de rupture des MEG au niveau des DRD pour les 45 médicaments traceurseu % 2016 12,7 1,0 <1 <1 DGESS Action 05505 Promotion des mécanismes de partage des risques en matière de santé Améliorer l’accessibilité financière des populations aux services de sauté Proportion de la population couverte par un mécanisme de partage de risque maladie % 2016 12 25 30 35 DGESS Nombre de nouveaux contacts par habitant et par an NBRE 2016 1,02 1,3 1,4 1,5 DGESS 45aPPendIxes Objectifs stratégique/ opérationnel Indicateurs d’impact /d’effet Référence Cibles Responsable Unité Année Valeur 2018 2019 2020 Action 05507 Promotion de la médecine et de la pharmacopée traditionnelles Renforcer la contribution de la médecine et de la pharmacopée traditionnelle a l’offre de soins de qualité Nombre de médicaments traditionnels enregistrés a la nomenclature nationale NBRE 2016 41 65 70 90 DGPML Nombre de tradipraticiens de santé autorisés a exercer NBRE 2016 29 200 250 300 DGPML Programme 056 Prestation des services de santé Réduire la morbidité , la mortalité pour une meilleure prevent°, des soins éfficaces et un changement des comportements Taux de mortalité maternelle RATIO 2016 341 243 243 243 DGESS Taux de mortalité des enfants de moins de 5 ans RATIO 2016 62,75 62,75 62,75 62,75 DGESS Action 05601 Participation communautaire Promouvoir les interventions intégrées à base communautaire en matière de santé Nbre d’ONG sous contrat de prestation avec le Ministère de la Santé NBRE 2016 252 252 252 252 DGS Nombre de villages couverts par les OBC-E NBRE 2016 8000 8000 8000 8000 DGS Action 05602 Réduction de lamobilitéet de la mortalité endémo-épidémies Promouvoir les interventions intégrées à base communautaire en matière de santé Nbre de nouveaus contacts par habitant et par an dans les structures de soins de ler échelon (CM et CSPS) NBRE 2016 1,02 1,3 1,4 1,5 DGESS Taux d’occupation des lits au niveau des hopitaux % 2016 50,5 60 65 70 DGS Action 05603 Offre de services de qualité en faveur de la santé de la mère et de l’enfant Améliorer la santé de la mère et de l’enfant Taux d’ accoucheinents assistés % 2016 80,9 >=87 >=90 >=90 DGESS Taux de réalisation des césariennes parmis les naissances attendues % 2016 >=3,5 >=3,8 >=3,9 >=4 DGESS Taux de couverture vaccinale des enfants en penta3 % 2016 103 100 100 100 DGESS Action 05604 Gestion sanitaire des catastrophes Renforcer la gestion sanitaire des catastrophes Taux de prise en charge des victimes des catastrophes % 2016 NA 80 80 80 DGS Proportion des hopitaux disposant d’un plan de riposte <plan blanc> % 2016 100 100 100 100 DGS APPENDIX 4: continued Objectifs stratégique/ opérationnel Indicateurs d’impact /d’effet Référence Cibles Responsable Unité Année Valeur 2018 2019 2020 Action 05605 Promotion de la santé Améliorer l’hygiène, I’assainissement et les comportements favorables á la santé Pourcentage de comités régionaux d’hygiène fonctionnels % 2016 ND 100 100 100 DGS Taux de réalisation physique du plan de communication en faveur de l’hygiène et de l’assainissement % 2016 >=85 >=85 >=85 DGS Action 05606 Assurance qualité des produits de santé Renforcer le système d’assurance qualité des produits de santé Taux de conformité des produits pharmaceutiques controlés % 2016 >=95 >=95 >=95 DGPML Nombre de produits controlés en post marketing NBRE 2016 339 360 370 380 DGPML Programme 057 Pilotage et soutien des services du Ministère de la Santé Renforcer les Capacités institutionnelles, organisationnelles, la gouvernance et le leadership dans le secteur de la santé Proportion des structures disposants de tous les outils de pilotage et de bonne et goouvernance % 2016 ND 100 100 100 Cab. Min. Action 05701 Pilotage, coordination des actions du Ministère de la Santé et collaboration intersectorielle Améliorer le pilotage stratégique des actions du Ministère de la santé et la collaboration intersectorielle Taux de réalisation des revues du secteur de la santé % 2016 100 100 100 100 Cab. Min. Nombre de CASEM santé tenus NBRE 2016 2 2 2 2 DGESS Action 05702 Accroissement des financements du secteur de la santé Mobiliser les financements au profit du secteur de la santé Taux de mobilisation des ressources additionnelles % 2016 ND >=90 >=90 >=90 DAF Taux d’absorption des ressources financières allouées % 2016 94,22 >=87 >87 >=88 DAF Proportion du budget de l’Etat allouée au Ministère de in Santé % 2016 12,4 13,5 14 14,5 DAF Action 05703 Gestion des ressources financières et matérielles Améliorer la gestion des ressources financières et matérielles mobilisées Pourcentage des structures ayant fait l’objet d’audits financiers % 2016 ND 100 100 100 SG Nombre d’inventaires de matériels realisés NBRE 2016 ND 2 2 2 DAF APPENDIX 4: continued Objectifs stratégique/ opérationnel Indicateurs d’impact /d’effet Référence Cibles Responsable Unité Année Valeur 2018 2019 2020 Action 05704 Gestion des ressources humaines Rationnaliser la gestion des ressources humaines pour la santé Pourcentage de CSPS remplissant les normes minima en personnel % 2016 93,2 >=95 >=95,3 >=96 DGESS Action 05705 Planification, suivi et évaluation Améliorer le processus de planification de suivi et d’évaluation au sein du secteur de la santé Proportion de structures disposant d’un plan d’action annuel % 2016 100 1000 100 100 DGESS Taux d’exécution physique des plans d’action % 2016 ND >=85 >=85 >=85 DGESS Action05706 Construction/réhabilitation et équipement d’infrastructures administratives et éducatives Développer les infrastructures administratives et éducatives, et leurs équipements Pourcentages des ECD fonctionnelles selon les normes en infrastructures % 2016 ND 100 100 100 DGESS Pourcentage des infrastructures éducatives publiques conformes aux normes % 2016 ND 90 90 90 DGESS Action 05708 Information sanitaire Développer l’information sanitaire Taux de promptitude des rapports d’activités des Formations Sanitaires publiques de soins % 2016 ND >=85 >=85 >=85 DGESS Taux complétude des rapports d’activités des Formations Sanitaires publiques de soins % 2016 97,1 100 100 100 DGESS Action 05709 Promotion de la recherche pour la santé Développer la recherche pour la santé Proportion de protocoles d’études et de recherches validés par un comité d’éthique ayant fait l’objet d’un rapport % 2016 ND 100 100 100 DGESS Proportion des résultats de recherches utilisés dans le processus de prise de décision % 2016 ND 60 65 70 DGESS Action 05710 Communication Améliorer la communication pour le changement de comportement des population Taux de réalisation physique annuel du plan de communication en faveur de l’hygiène et de l’assainissement % 2016 ND >85 >85 >85 DGS Source: Budget – expenditure, Ministry of Health. Note: an error has crept into the strategic objective for action 05602: Reducing endemic/epidemic morbidity and mortality should in fact be “Improve the supply of quality health services”. APPENDIX 4: continued

For additional information, please contact: Health Systems Governance and Financing Department Universal Health Coverage and Health Systems Cluster World Health Organization 20, avenue Appia 1211 Geneva 27 Switzerland Email: healthfinancing@who.int Website: http://www.who.int/health_financing HEALTH FINANCING CASE STUDY No 11 BUDGETING IN HEALTH