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Exploratory review of financial autonomy at primary care level

A presentation entitled 'Exploratory review of financial autonomy at primary care level', given by Professor Sophie Witter at the 6th Meeting of the Montreux Collaborative Conference

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Exploratory review of financial
autonomy at primary care level
Sophie Witter, Maria Bertone, Lucas Sempe, Quentin Baglione
Methods
• Scoping literature review
(n=91)
• Extraction from HFPM data
(n=25 countries)
• Expert interviews (n=12)
• Team’s own insights
• Formal literature is limited in
depth
• But combined methods
yielded insights across wide
geographies (c. 40 countries)
How much autonomy do primary providers have?
• Varies by area, by low
autonomy in general (<40%
manage and retain funds)
• Somewhat of gradient by
economic level, but not
consistently
Source: Hanson et al. 2022;
data from 75 LMICs
Financial
autonomy
scenarios,
by budget cycle
Low financial autonomy scenario Medium financial autonomy scenario High financial autonomy scenario
Planning of budget Budgets are allocated from above
with no scope for facilities to
influence them
Facilities make inputs into budget
process but can only influence the final
budget in limited ways
Facilities structure own budgets
according to their identified activities
and needs
Mobilising and
retention of
additional funds
Funds are fixed externally; no
ability to mobilise additional funds
at facility level. Funds remitted to
Treasury or district/higher level. All
funds spent within financial year
Most funds are fixed; some small
(marginal) additional fund mobilisation
is permitted and retained at facility level,
with rest remitted to higher levels. One
part of revenues can be retained (e.g.
use of user fee or PBF income) across
years
Able to raise funds independently from
multiple sources, as available, without
restrictions. All funds raised are
retained at facility level. All funds can
be retained across years, if unspent
Management,
including
reallocation
Budgets are fixed (often by line
item) and changes across them are
very cumbersome and limited (or
not possible). Most of expenditure
is ring-fenced. Where multiple
revenue sources exist, there are
strict rules about how they can be
used
Some in-year changes in budget are
possible, with higher authorisation.
There is some flexibility around
deployment of different revenue
streams according to facility needs
Facilities can shift funds across budget
lines within clear parameters set out in
advance (with simple approval
procedures where this threshold is
exceeded), drawing flexibly from the
different funding streams that they can
access
Expenditure Most expenditure is made at higher
levels (on behalf of the facilities),
with inputs provided in kind.
Facilities do not need or have bank
accounts
Facilities have access to limited funds to
use for small costs (often minor
operational costs, such as cleaning and
maintenance). They may have bank
accounts but can also operate through
petty cash
Facilities can actively manage their
major expenditure items, including for
locally hired staffing, medicines and
supplies and operational costs. They all
have bank accounts
Reporting Facilities have no financial reporting
requirements as they are not
recognised within the PFM system
Facilities report on expenditure via
higher level (such as districts) for funds
released by them to the facilities
Facilities are spending units, accounting
within the PFM system for their
expenditure
Primary care
facility
financial
autonomy
- Planning
- Mobilising
funds
- Managing
- Expenditu
re
- Reporting
• PFM and legal
frameworks, e.g. rules on
retention of locally
generated funds
• Provider payment
mechanisms (e.g.
capitation and case based
payments typically
support FA more)
• Budget structures (e.g.
management of staff
costs versus capital and
recurrent)
• Status of providers within
PFM system
• Number of funding
streams to primary
providers and their
regulations
• Sufficient,
predictable and
timely funding
• Staff: time and skills;
able and willing to
develop leadership
mind-set
- Clear guidance,
effective tools and
systems for
planning, budgeting,
monitoring
- Alignment with PFM
(e.g. reduced input-
based controls;
greater flexibility to
adjust budgets)
- Simplification of
PFM rules to make
spending less
onerous
- Functional oversight
and accountability
mechanisms
- Availability of
relevant resources in
facility or locally (e.g.
ICT, medicines,
infrastructure)
Flexible use of
resources and
innovative strategies
to address health
needs (and crises)
More active
community
participation
• Better facility
performance
(quality,
quantity,
access,
equity,
responsive-
ness,
efficiency)
• Resilience of
services in
face of
shocks
Reduced waste
Increased motivation
of health staff (via
recognition, working
environment and/or
pay)
Improved availability
of commodities etc.
Better planning,
managing, oversight,
accountability
Fiduciary risk
Low quality of drugs,
inefficiencies in
procurement
Increased workload
Key contextual factors Prerequisites for autonomy that leads to
positive outcomes
Potential effects (positive and negative)
• Broader politico-
administrative context
and ongoing reforms
(e.g. strategic
purchasing, PFM,
decentralisation, reforms
to user fees)
• Willingness to give more
control to facilities by
major actors (including
donors)
Extractive practices (if
incentives to increase
patient charges)
Key message 1: better conceptualisation
• Autonomy has many aspects, which need more detailed unpicking,
potentially along the lines of the typology which we have developed
here
• Facilities may have considerable autonomy in one aspect but not another, and
their interaction is important
• Equally, autonomy often varies according to funding sources and expenditure
types, which can be a complex mix at facility level.
• It is not a binary choice (autonomous or not)
• Nor is it a simple continuum (with more autonomy always being better - the
arrangements need to follow the contextual needs)

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Exploratory review of financial autonomy at primary care level

  • 1. Exploratory review of financial autonomy at primary care level Sophie Witter, Maria Bertone, Lucas Sempe, Quentin Baglione
  • 2. Methods • Scoping literature review (n=91) • Extraction from HFPM data (n=25 countries) • Expert interviews (n=12) • Team’s own insights • Formal literature is limited in depth • But combined methods yielded insights across wide geographies (c. 40 countries)
  • 3. How much autonomy do primary providers have? • Varies by area, by low autonomy in general (<40% manage and retain funds) • Somewhat of gradient by economic level, but not consistently Source: Hanson et al. 2022; data from 75 LMICs
  • 4. Financial autonomy scenarios, by budget cycle Low financial autonomy scenario Medium financial autonomy scenario High financial autonomy scenario Planning of budget Budgets are allocated from above with no scope for facilities to influence them Facilities make inputs into budget process but can only influence the final budget in limited ways Facilities structure own budgets according to their identified activities and needs Mobilising and retention of additional funds Funds are fixed externally; no ability to mobilise additional funds at facility level. Funds remitted to Treasury or district/higher level. All funds spent within financial year Most funds are fixed; some small (marginal) additional fund mobilisation is permitted and retained at facility level, with rest remitted to higher levels. One part of revenues can be retained (e.g. use of user fee or PBF income) across years Able to raise funds independently from multiple sources, as available, without restrictions. All funds raised are retained at facility level. All funds can be retained across years, if unspent Management, including reallocation Budgets are fixed (often by line item) and changes across them are very cumbersome and limited (or not possible). Most of expenditure is ring-fenced. Where multiple revenue sources exist, there are strict rules about how they can be used Some in-year changes in budget are possible, with higher authorisation. There is some flexibility around deployment of different revenue streams according to facility needs Facilities can shift funds across budget lines within clear parameters set out in advance (with simple approval procedures where this threshold is exceeded), drawing flexibly from the different funding streams that they can access Expenditure Most expenditure is made at higher levels (on behalf of the facilities), with inputs provided in kind. Facilities do not need or have bank accounts Facilities have access to limited funds to use for small costs (often minor operational costs, such as cleaning and maintenance). They may have bank accounts but can also operate through petty cash Facilities can actively manage their major expenditure items, including for locally hired staffing, medicines and supplies and operational costs. They all have bank accounts Reporting Facilities have no financial reporting requirements as they are not recognised within the PFM system Facilities report on expenditure via higher level (such as districts) for funds released by them to the facilities Facilities are spending units, accounting within the PFM system for their expenditure
  • 5. Primary care facility financial autonomy - Planning - Mobilising funds - Managing - Expenditu re - Reporting • PFM and legal frameworks, e.g. rules on retention of locally generated funds • Provider payment mechanisms (e.g. capitation and case based payments typically support FA more) • Budget structures (e.g. management of staff costs versus capital and recurrent) • Status of providers within PFM system • Number of funding streams to primary providers and their regulations • Sufficient, predictable and timely funding • Staff: time and skills; able and willing to develop leadership mind-set - Clear guidance, effective tools and systems for planning, budgeting, monitoring - Alignment with PFM (e.g. reduced input- based controls; greater flexibility to adjust budgets) - Simplification of PFM rules to make spending less onerous - Functional oversight and accountability mechanisms - Availability of relevant resources in facility or locally (e.g. ICT, medicines, infrastructure) Flexible use of resources and innovative strategies to address health needs (and crises) More active community participation • Better facility performance (quality, quantity, access, equity, responsive- ness, efficiency) • Resilience of services in face of shocks Reduced waste Increased motivation of health staff (via recognition, working environment and/or pay) Improved availability of commodities etc. Better planning, managing, oversight, accountability Fiduciary risk Low quality of drugs, inefficiencies in procurement Increased workload Key contextual factors Prerequisites for autonomy that leads to positive outcomes Potential effects (positive and negative) • Broader politico- administrative context and ongoing reforms (e.g. strategic purchasing, PFM, decentralisation, reforms to user fees) • Willingness to give more control to facilities by major actors (including donors) Extractive practices (if incentives to increase patient charges)
  • 6. Key message 1: better conceptualisation • Autonomy has many aspects, which need more detailed unpicking, potentially along the lines of the typology which we have developed here • Facilities may have considerable autonomy in one aspect but not another, and their interaction is important • Equally, autonomy often varies according to funding sources and expenditure types, which can be a complex mix at facility level. • It is not a binary choice (autonomous or not) • Nor is it a simple continuum (with more autonomy always being better - the arrangements need to follow the contextual needs)
  • 7. Key message 2: raise the profile of the issue • Autonomy at primary care level has not received as much attention as that at hospital level • likely reflects the fact that in most health care systems, public primary care facilities have had limited funds and limited autonomy over them (as highlighted in our analysis of the HFPM data) • Need for more focus on this issue, including in-depth case studies to elaborate the nature and strength of the relationships in the preliminary conceptual framework • Areas to explore include: • different ways of increasing primary care financial autonomy without high transaction costs; • better documenting the role of multiple funding streams at primary care level, and their interaction with financial autonomy; • understanding the role of different types of expenditure (e.g. management of staffing budgets) and different facility characteristics, and how these interact with financial autonomy; • implications for PFM and other system components (e.g. accountability systems) • role of new digital technologies in relation to financial autonomy • cost (e.g. investment in capacity) and benefits (e.g. improved performance) of increasing financial autonomy
  • 8. Key message 3: key features The data is not strong enough to draw firm conclusions on optimal design (which also needs to fit to context in any case). However, reflecting on our typology, some elements appear to be particularly important to support autonomy, including: 1) ability to retain at least some funds generated; 2) ability to influence budgets that apply to their level; 3) ability to vire across budget lines within reasonable limits; 4) ability to address at minimum routine operational costs without prohibitive approvals and accounting.
  • 9. Key message 4: put it in context • Autonomy alone does not guarantee improved performance • efforts at addressing financial autonomy should also resolve operational autonomy issues • there are numerous other (pre)conditions that need to be carefully considered and tailored to the context (administrative, PFM, provider payment mix, etc.) such as skills, knowledge, organisational culture, and willingness to actively manage resources) • what matters here is how systems work in practice, rather than in theory • To achieve it, it is essential to manage the alignment between strategic purchasing and PFM arrangements • and move out of “project” logic towards systemic and integrated primary care funding, which strengthens the health system in the longer term and has a better chance of being sustained
  • 10. Key message 5: consider functional aspects • Considering different expenditure types, certain elements lend themselves more to central control • most obviously capital costs (being multi-year and requiring special planning across primary care boundaries) and allocations to programmes and areas • Staffing budgets are more complex – typically, staff are centrally funded, linked to wider civil service employment, however, this does impact on local managerial influence over staffing mix, which is a major input to services. • Bonus schemes tend to be nationally regulated for reasons of smoothing the labour market. • In many systems there is more flexibility at facility level over hiring of contractual staff. • Medicines and supplies are also usually hybrid, with some central procurement but allowances for ‘emergency’ top ups at facility level. • Most autonomous are operating costs, which should be determined by facilities, whether expended directly by them or by a district or equivalent authority.
  • 11. Key message 6: pay attention to drivers and management of change • Managing the political economy of change should also not be underestimated, especially as increased financial autonomy at primary care level can be threatening to other actors • Some reform processes, such as decentralisation, have been detrimental to provider financial autonomy. • Many of the changes have come from reforms to purchasing and provider payments, with varying degrees of external support. • The cost of system changes which affect a large primary care sector are significant, if capacity and infrastructure need to be built, as is likely.
  • 12. Key message 7: understand risks • The risks of increasing autonomy are less in terms of fiduciary risks (primary care centres usually handle small amounts of money), but more in terms of increased workload, inefficiencies and missed opportunities due to other constraints • such as complexity or other restrictions that stop autonomy from being exercised in reality • Although accountability is important, the country data suggests that accountability measures (to control financial risks) may be squeezing out autonomy, although this topic needs more attention
  • 13. Key message 8: keep an outcome focus • Autonomy is not a goal in its own right, but a means to an end (of better performance of primary care facilities and better health outcomes, including preventative) • Reforms should be monitored to track these important outcomes