2014年-世界发展银行全球_Timor-Leste_Health_Resource_Tracking_Study_88页_3mb

Summary of the Timor-Leste Health Resource Tracking Study

Core Content

The Timor-Leste Health Resource Tracking Study (Report No: AUS4291) was conducted by the World Bank in September 2014 to improve the flow of critical cash and in-kind resources to districts and health centers. The study aimed to identify and propose solutions for the most significant impediments in the public financial management (PFM) cycle that affect the timely and sufficient delivery of health resources. It focused on three key inputs: operating cash for District Health Services (DHS) and Community Health Centers (CHC), fuel for vehicles and generators, and vehicle repairs and maintenance.

The study was carried out in collaboration with the Ministry of Health (MoH), and supported by the Australian Department of Foreign Affairs and Trade (DFAT) and the European Commission. It used a mix of data collection, interviews, transaction analysis, and document review to evaluate the PFM system's performance and suggest improvements.

Main Findings

1. Weak Link Between Planning, Budgeting, and Reporting

• The National Health Sector Strategic Plan (NHSSP) provides a strong policy framework, but district-level activity planning is not effectively reflected in the goods and services budget (G&S budget).
• There is a disconnect between service needs and budget allocation, leading to over- or under-spending on specific line items.
• Expenditure control is weak, as spending requests are only checked against the overall G&S budget, not individual line items.
• The MoH initiates spending on centrally procured items, while DHS spends their operating cash, creating a dual budget holder system that can lead to budget imbalances.

2. Late and Slow Release of Funds

• Operating cash for districts is supposed to be an "advance", but the first payment is often delayed for several months.
• Fuel payments are frequently delayed, with the first fuel delivery arriving in April 2013, and payment taking 62 days on average.
• Vehicle repair payments are also delayed, with suppliers taking at least two months to be paid, and most payments in 2013 being for debt from previous years.

3. Weak Contract Management

• Contracts are often not renewed on time, leading to uncertainty among suppliers.
• Contract amendments are used to extend agreements, but they are approved after the initial term, creating inefficiencies.
• Contracts do not include performance criteria, and transport and routine maintenance are not covered in some cases.

4. Systemic Issues

• These issues reinforce each other, leading to a self-perpetuating cycle.
• The district G&S budgets are not aligned with national policy or district-level plans, making the budget a poor reflection of primary healthcare needs.
• Weak internal controls allow districts to overspend, resulting in debt to suppliers and creditors.
• Late fund releases create budget shortfalls later in the year, as funds are released after obligations to debt repayment have already been incurred.

Key Recommendations

Cross-Cutting Recommendations

• Audit all district-level debt, including off-the-books debt.
• Use national program goals to guide district allocations and ensure timely budget envelopes.
• Provide flexible operating cash to districts and CHCs using a budget norm or formula.
• Utilize program/activity-based budgeting codes in the chart of accounts.
• Simplify the steps to release district operating cash.
• Implement the duodecimo provision to ensure fund availability even when the national budget is delayed.
• Submit the Commitment Payment Voucher (CPV) at the start of the year and push the first payment based on approved expenditure plans.
• Improve processing speed of requisition and payment documents.
• Ensure early contract procurement to avoid delays.
• Include performance criteria in supplier contracts and set standards for MoH Logistics and Finance departments.
• Consider decentralizing vehicle maintenance, simple repair, and fuel provision to districts, within a framework ensuring technical capacity and quality.

Recommendations for Operational Cash

• Clarify and standardize guidelines for allowable expenses in the imprest account.
• Simplify the steps to release district operating cash.
• Provide training to districts on financial and reporting systems.
• Address fund flow delays by establishing clear guidelines for CHC-level imprest and pushing funds based on these guidelines.

Recommendations for Fuel

• Plan fuel budgets based on district needs, including vehicles, travel, and distance.
• Improve budget reporting on fuel expenditures and usage.
• Clarify how motorcycle fuel is planned, where it is budgeted, and at what levels it can be procured.
• Consider a complementary period for fuel payment requests to avoid service interruptions near the end of the year.
• Allow local procurement of fuel to complement or replace in-kind delivery.
• Modify the voucher system to include district-specific or reserve vouchers.
• Produce guidelines and provide necessary equipment to ensure adequate fuel supplies and reserves at the CHC level.

Recommendations for Vehicle Repair and Maintenance

• Establish an easily updatable asset register for vehicles and motorcycles.
• Conduct economic evaluations and establish guidelines for vehicle replacement and disposal.
• Rationalize vehicle distribution based on terrain and need.
• Develop a planning and budgeting process for district-level maintenance and repair.
• Distinguish budgeting, requisition, and payment processes for maintenance and repairs.
• Incorporate performance incentives into national repair service contracts.
• Consider decentralizing simpler maintenance and repair to districts.
• Staff districts with dedicated transport managers or expand driver training to include routine maintenance.
• Provide backup vehicles during repair periods.
• Outsource fleet management and provision to the private sector.
• Develop a consolidated transportation policy and manual, and disseminate it widely.

Next Steps

The study emphasizes the importance of immediate implementation of incremental reforms while also assessing the feasibility and impact of more ambitious initiatives. The PFM Roadmap is used as a starting point for recommendations, which range from quick wins to systemic changes. The goal is to ensure timely and sufficient delivery of health resources to frontline service providers, which is essential for the health of the population of Timor-Leste.