Follow the money: How to increase the transparency, efficiency and accountability of health care spending

It is estimated that $0.23 of every $1 spent on health is directed towards vertical programs in HIV/AIDS, while in some countries as little as $0.06 is directed towards family planning. In many low-income countries, however, only a fraction of that amount — less than 20 percent — actually reaches health care providers at the point of care.

To put in more finite terms: Of the $2.6 billion in international commitments generated by the Family Planning Summit in 2012, only $520 million will be directed towards point of service. This suggests that a staggering $2 billion gets distributed somewhere in the health system: but to where?

Numerous studies and methodologies have attempted to identify financial “leakages” in health care. For example, the 2000 public expenditure tracking survey in Rwanda showed that of the total amount of funds transferred to the regional health offices, the amount received by the district health offices varied between 1.9 percent and 45.7 percent. The discrepancies were presumed to be due to leakages in the system, poor bookkeeping, or both — resulting in a failure of accountability and reduced services to those who need them most.

The low level of resources reaching facilities has forced many to exercise alternate resource mobilization methods such as user fees. But even these internally generated funds have fallen victim to substantial leakage. In Kenya, while two-thirds of the national health budget does in fact reach the facility level, it has been reported that user fee and community development fund leakages amount to 38 percent and 56 percent respectively. In some cases it has been noted that staff use up to 70 percent of drugs and supplies for personal gain.

Leakage of health funds hampers the provision of health services in many ways. If facilities do not receive allocated amounts of funds, they may be forced to find alternative means to generate revenue, such as additional out-of-pocket expenditures in which the poor undoubtedly suffer the most. And when those additional expenses are not fully directed towards treatment, goods or services — and subject to further leakage — this is cause for greater concern. Indeed, service quality and concerns around provider integrity may lead individuals to seek care at higher-cost private facilities, potentially pushing families further into poverty.

National health accounts, public expenditure reviews and other traditional resource tracking tools alone are not sufficient for identifying areas of “leakage” — and a new approach is needed.  

The Resource Tracking Heat Map is an innovative approach developed by Deloitte Consulting LLP that is designed to help countries visually follow the flow of funding through the health system and help improve the efficiency of funds flowing to health services. Following the dollar as it makes its way through the system is analogous to injecting a medical dye and using its movements to diagnose underlying problems. Through a color-coded display, the heat map provides a visual summary of where resources are getting stuck in a health system and why funds may not be reaching the point-of-care.

The concept draws from energy transmission and medicine, paired with industry-standard, public financial management practices that use a six-point scale to rate the efficiency and severity of the resource flow variances. Different colors on the heat map represent different types of constraints and illustrate relative severity. For example, significant losses in transmission show up as red, while low transmission loss shows up as green.

This framework can measure the timeliness of funds disbursed at each administrative level of the health system — for example, if a provider was expecting a disbursement in January but received it in March; the amount of funding reaching each administrative level of the health system compared to what was actually planned — for example, if a provider was supposed to receive $10,000 but only received $5,000; and the impact of the timeliness and amount of funds received on health care delivery. The purpose is to understand the impact of these variances on health outcomes: If payments to providers are untimely or insufficient, this may lead to either delayed or forgone care.

Mapping of resource flows should be tailored to the local context by focusing only on relevant administrative level funding pools, geographic regions and program areas. Subsequently, data to be inputted into the framework is collected from a variety of sources, from the central government level to local health providers. The heat map highlights loss by severity level: With the objective to decrease the level of loss across the system and not necessarily to eliminate it altogether, not all variances can or should be addressed. Indeed, countries should decide which are “acceptable” or “tolerable” and address them accordingly.

Once mitigation strategies are employed, it is expected that the number and severity of the variances will decrease over each measurement period, potentially reducing the overall loss in resources allocated from source to point-of-care, resulting in improved program performance and greater impact of every dollar spent.

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Healthy Means is an online conversation hosted by Devex in partnership with Concern Worldwide, Gavi, GlaxoSmithKline, International Federation of Pharmaceutical Manufacturers & Associations, International Federation of Red Cross and Red Crescent Societies, Johnson & Johnson and the United Nations Population Fund to showcase new ideas and ways we can work together to expand health care and live better lives.