A review into best practices for health systems planning and budgeting in West Africa countries. Conducting for the UNICEF Harmonization of Health Systems in Africa COP

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Literature Review on Health Sector Planning and
Budgeting in West African Countries
Ebele Mogo

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Focus of this literature review
 To uncover best practices in health sector planning and
budgeting
 To uncover factors that enhance or impede the alignment of
health systems budgeting and planning processes
 To propose recommendations for improving the alignment of
budgeting and planning processes

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Procedure for conducting the
literature review
 Scientific databases: Google Scholar, PubMed, Science Direct,
Health Policy and Planning
 Key words searched: health sector planning, health sector
budgeting, health sector planning and budgeting, health system
planning, health system budgeting, health system planning and
budgeting, health budgeting, health planning, health planning
and budgeting
 Number of articles found: 60

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Exclusion criteria
 19 articles from before 2000 removed. 2000 used as cutoff
instead of 2010 due to limited number of articles
 6 articles repeated on multiple databases removed
 18 articles removed due to irrelevance to research question
e.g. focus on theory, an intervention or versus on the health
system
 Yielded a final total of 18 articles

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Analysis
 Conceptual framework by Walt & Gibson (1994)
 Assessed context, process, actors, and content of articles
 In addition assessed alignment, and factors facilitating or
impeding alignment in each article

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Context
 Countries: Kenya, Uganda, Canada, Pakistan, United States,
Ghana, Guatemala, Turkmenistan, Brazil, Lesotho, Australia,
England
 Levels of government: district/provincial/regional level, national
level, veteran’s health administration healthcare system,
community level

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Process of budgeting and planning
at the district level
 Hierarchical/Top-down : Policy and budgeting goals borrowed
from global community or based on nepotism/political agenda.
Implemented mechanistically without adaptation or
accountability to the community
 Community Engaged: Community led planning through voting
or creating a committee that created health plan and allocated
budget based on local needs
 District level budgeting and planning: Process led by district
level stakeholders who decided on priorities using decision
analysis software, needs assessments, personal experience
and/or evidence. Funds distributed based on identified priorities

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Process of budgeting and planning
at the national level and VHA
 Planning was based on evidence (gotten through planning tools
or surveys) or political agenda
 Based on goals identified through planning, a budget would be
created and submitted to the health department for review,
amendment and approval
 VHA: Performance based budgeting were finances were
redistributed to more efficient hospitals

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Process of budgeting at the
community level
 Dialogue with residents and local leaders
 Use of social traditions to promote community bonding
 Needs assessment in each community
 Resources allocated based on needs and capacity
 Posting of community health workers to community health
compounds

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Actors in budgeting and planning
 Community level: elders, community members, health facility
staff and management, nurses, volunteers, local non-
governmental organizations, elected officials, community
leaders
 National level: policy makers, donors, international
organizations e.g the World Bank, Minister of Health, district
health officials, central government
 District level: district management, clinical staff, non-clinical
staff, administrative staff, finance staff and senior management

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Content of budgeting and planning
processes
 Budget: proposed budget, details of funds, personnel,
equipment, community engagement, frequency of activities
planned, fiscal year
 Planning: proposed work plans, recommendations from expert
panels and working groups, priorities, programme indicators,
meeting minutes, estimates for resource use

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Features Of Alignment
 Effective health system decentralization
 Budgeting and planning considered population needs not just
global recommendations or historical data
 Technical tools were not imposed in a top down fashion but
were adapted to community needs, with local capacity built to
use these tools

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Best Practices For Alignment
 Proper Funding: affects community engagement in planning and
budgeting, capacity of staff, quality of service delivery, and
implementation of plans
 Effective Governance: top down processes impede alignment;
multiplicity of actors can lead to misalignment; political
commitment and transparency facilitate alignment while political
resistance or instability impede planning, budgeting and
implementation
 Proper Consideration of Logistics: short time frames for planning
led to poor translation and poor capacity of local community to
plan, budget and implement; misalignment between the timing for
planning and funding impeded alignment. Allowing enough time to
plan, iterate and coordinate planning with budget allowed for
success

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Features of Poor Alignment
 Poor implementation of national goals at the local level: due to poor
capacity building at the local level, top-down approaches to decision
making, poor adaptation of technical approaches like burden of
disease and cost effectiveness tools
 Poor budgeting: poor disclosure of information, poor organization,
inadequate availability of funds, underfunding of health facilities,
shortage of staff, poor funding of maintenance and medical supplies
 Poor organizational integration: planning and financial allocation were
made at different organizational levels and there was no
communication between the two levels
 Poor stakeholder participation: exclusion of budget holders and
district health officers from decision making, poor disclosure of cost
information thus disconnecting finances from health programming

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Best Practices For Alignment
 Availability of Information/Evidence: Poor data systems affected
availability of data on costs, resources, community health
expenditure, health activities and health utilization. National
indicators did not represent community needs and often
disincentivised adaptation of data collection to community
needs
 Effective Organization: poor leadership, poor guidelines, poor
role definition, poor accountability, poor communication
between financial and clinical personnel inhibited alignment

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Best Practices For Alignment
 Capacity: staff strength, clarity about principles of planning and
budgeting, were needed for alignment. This was often missing to a
predominant medical orientation of staff and less of a financial
orientation. Need for communication between medical and
financial sectors and integration of these skillsets
 Political will and context specificity of health reform and policies:
political support such as a champion, consideration of community
needs, adaptation, context specificity, accountability, equity and
communication between policy makers and implementers and
community are needed for alignment