2013年-世界发展银行全球_Kingdom_of_Bhutan_Human_Development_Public_Expenditure_Review_94页_2mb

Summary of the Human Development Public Expenditure Review in Bhutan

Core Content

The Human Development Public Expenditure Review (HD PER) conducted by the World Bank in March 2013 provides an in-depth analysis of the financial management and resource allocation in Bhutan's health and education sectors. The report is part of a broader effort to support Bhutan's development trajectory, particularly in the context of increasing demands for public services due to demographic changes and the need to align with regional standards.

Main Objectives

The primary objectives of the HD PER were to:

• Assess the effectiveness of current financial resources in Bhutan for health and education.
• Provide evidence to inform policy decisions, especially in relation to public systems management.
• Support the preparation of the 11th Five-Year Plan (11FYP).
• Contribute to the Development Policy Credit (DPC) series.

Key Findings

Health Sector

• Bhutan has made significant progress in achieving universal health coverage, with public health services largely free of cost.
• Public health expenditure in 2009/10 was 6.27% of total government expenditure and 3.23% of GDP, among the highest in South Asia.
• Government funding accounts for 88% of health resources, while household out-of-pocket spending is around 11%, with transport costs excluded from this figure.
• Geographic disparities are evident in health spending, with districts like Tashigang and Wangdue spending significantly more than Bumthang and Lhuentse.
• Health infrastructure and access are uneven, with remote areas facing significant challenges in reaching health facilities.
• Costing studies show that health services at higher levels (e.g., referral hospitals) are more expensive than those at lower levels (e.g., Basic Health Units).
• The referral system is not functioning effectively, leading to overload at national referral hospitals.
• The Special Consultation Service (SCS) pilot program at JDWNRH showed mixed results, with many patients finding paid services less beneficial than free ones.
• Equity challenges persist, particularly in access to health services for the poor, with the poorest quintile taking up to 115 minutes to reach a health facility, compared to 33 minutes for the richest.

Education Sector

• Bhutan has an organized public education system with over 650 schools, 180,000 students, and nearly 9,000 teachers.
• The country is on track to achieve MDGs in education by the end of the 10FYP (2008–2013), with gender parity in primary education and near-parity in secondary and higher education.
• Public education expenditure was 7.3% of GDP and 16.7% of total government spending in 2009/10, also among the highest in South Asia.
• Development partners are reducing their financial support, which may affect the ability to finance the education sector under the 11FYP.
• Primary education has high enrollment and completion rates, indicating effective public financing.
• However, learning outcomes are not as strong as enrollment figures, suggesting a need for better quality improvement and teacher support.
• Poverty is a major barrier to education access, with higher poverty areas showing lower school attendance.
• Out-of-pocket education expenditure is significant, with households spending an average of 26% of their income on education, the highest among all household expenditures for non-food consumption.

Policy Challenges and Reform Options

• Sustainability of public spending is a major concern, especially with the lack of economic diversification and external dependency.
• Efficiency gains are needed in the public sector to free up fiscal space and support future social sector expenditures.
• Private sector involvement could help alleviate financial pressures, especially in health and education.
• Equity issues in both sectors must be addressed through targeted policies and improved access for marginalized groups.
• Referral system improvements and cost-effective service delivery mechanisms are essential for the health sector.
• Teacher training and performance incentives are necessary to enhance the quality of education.
• Adaptation of staffing and resource allocation to changing workloads in health facilities and education institutions is crucial.
• Flexibility in remuneration systems and civil service rules may be required to promote performance-based outcomes.

Methodology

The HD PER utilized:

• Secondary data analysis from existing studies and government monitoring systems.
• Data from surveys such as the Bhutan Living Standards Survey (BLSS) and National Health Accounts (NHA).
• GIS tools to analyze health infrastructure, access, and distribution of health indicators across districts.
• Costing studies to evaluate the efficiency of health services at different levels.
• Focus group discussions (FGDs) and key informant interviews (KII) to gather qualitative insights.

Public Sector Management

• Bhutan transitioned to a Democratic Constitutional Monarchy in 2008, with a two-house Parliament and local governance structures.
• Administrative decentralization is a recent development, with local institutions (Dzongkhag and Geog Tshogdue) playing a key role in governance.
• The Public Finance Act (2007) introduced a three-year budget policy and formula-based allocation for local governments.
• Annual Audit Reports (AAR) and Government Consolidated Accounts (GCA) are used for financial oversight, with audits conducted by the Royal Audit Authority (RAA).
• The Government to Citizen (G2C) program aims to improve service delivery efficiency and reduce access time for citizens.

Conclusion

The HD PER highlights the need for strategic reforms in Bhutan’s health and education sectors to ensure sustainable and equitable public service delivery. While Bhutan has made commendable progress in human development, the increasing financial demands, economic constraints, and capacity limitations require careful policy planning and implementation. The report serves as a foundation for future policy decisions and the preparation of the 11FYP, emphasizing the importance of efficiency, equity, and quality in public expenditure management.