2017年-世界发展银行全球_Lesotho_Public_Health_Sector_Expenditure_Review_91页_2mb

Summary of Public Health Sector Expenditure Review in Lesotho (2017)

Core Content

The Public Health Sector Expenditure Review (PER) for Lesotho, conducted by the Government of Lesotho, UNICEF, and the World Bank Group, provides an in-depth analysis of the country's health sector spending from FY 2011/12 to FY 2015/16. The report highlights the challenges and opportunities for improving the efficiency, equity, and effectiveness of health financing in Lesotho, a lower middle-income, mountainous country surrounded by South Africa.

Main Findings

• Health System Overview: Lesotho has a fragmented health system with multiple pools of resources from both government and donor sources, and service providers operating under different priorities and mechanisms. There is a lack of accountability and oversight.

• Health Outcomes: Lesotho has among the highest maternal and neonatal mortality rates globally, with MMR at 1,024 per 100,000, IMR at 59 per 1,000 live births, and NMR at 34 per 1,000 live births. Despite improvements in IMR, these rates remain a significant concern.

• Disease Burden: HIV/AIDS is the leading cause of mortality in Lesotho, accounting for 41.4% of all deaths in 2014. The country has one of the highest HIV prevalence rates in the world (24.6% among adults aged 15–49 in 2014), with TB incidence also being the highest globally (788 per 100,000 in 2016). HIV and TB are closely linked, with 74% of TB patients testing positive for HIV in 2014.

• Health Infrastructure: The Ministry of Health and Social Welfare (MoH) is responsible for developing health policy, standards, and guidelines, and mobilizing resources. The health system includes a mix of government and outsourced facilities, such as the Queen Mamohato Memorial Hospital (QMMH) and the Christian Health Association of Lesotho (CHAL), which operates 61 primary health centers and 8 district hospitals.

• Expenditure Trends:

  • The recurrent budget for the MoH grew at a CAGR of 9% over the five-year period.
  • CHAL's subvention increased by 121%, with its facilities providing healthcare to about a third to half of all inpatients and a quarter of all outpatients.
  • The PPP with Tsepong accounts for approximately 30% of MoH recurrent expenditure.
  • Budget utilization rates vary significantly across districts and facilities, with some district hospitals underutilizing their budgets by as low as 63% in FY 2015/16.

Key Recommendations

• Improve Institutional Capacity: Strengthen systems for collecting, validating, and using evidence on health outcomes, service delivery, and expenditure to guide decision-making.

• Enhance Allocative Equity: Implement need-based and capitation formulas to ensure fair distribution of funds across districts and facilities.

• Revise Payment Systems: Change the payment system for hospitals to base allocations on service delivery (volume and quality), not input-based norms. Address the low bed occupancy rate (32%) and staffing imbalances.

• Strengthen Oversight: Create institutional capacity within the MoH to monitor and oversee outsourced services, as they currently absorb over 52% of the MoH budget.

• Revise CHAL Agreement: Update the Memorandum of Understanding (MoU) with CHAL to ensure greater accountability and link payments to service delivery outcomes.

• Improve QMMH Efficiency: Conduct further studies on the efficiency and quality of services at QMMH and review the PPP contract to optimize service delivery and payment structures.

• Enhance Referral Systems: Improve the referral system between district hospitals and QMMH to reduce unnecessary referrals and improve patient outcomes.

• Conduct Further Studies: Explore efficiency and quality differences between CHAL and government facilities, analyze the absorptive capacity of the MoH budget, and investigate the reasons for the decline in development budget expenditure.

Data Sources and Methodology

• Recurrent Expenditure: Extracted from the Integrated Financial Management Information System (IFMIS) in January 2017. However, the data is not final due to frequent updates and reallocations.

• Development Expenditure: Collected from the Development Budget Sources and the Finpro system, which is audited and more reliable for tracking total development expenditure.

• Non-Development Expenditure: Included from the MoH Planning Department's resource mapping database, which is self-reported and thus may not be fully accurate.

Conclusion

The PER identifies critical gaps in the comprehensiveness and consistency of financial information across the health sector, as well as significant challenges in service delivery performance. It emphasizes the need for the Government of Lesotho to improve the management and utilization of health funds to achieve universal health coverage, especially under tight budget constraints. The report also underscores the importance of strengthening accountability, oversight, and performance monitoring to ensure that resources are used effectively and equitably.