"We have a lot of structures, systems, and processes. Guidelines are quite well laid out, but we have a problem with implementation," remarked Mavis MacCarthy, Executive Director of MCM Associates at the June 24, 2009, launch of "Improving Ministry of Health and Ministry of Finance Relationships for Increased Health Funding," a report from the Woodrow Wilson International Center for Scholars' Global Health Initiative (GHI). To improve this implementation and increase budget allocations for the health sector, GHI worked with consultants in Ghana, Senegal, and Uganda to assess technical skills within these countries' ministries of finance (MOF) and ministries of health (MOH), as well as the communication between the ministries.
The assessment results were presented to representatives from the MOF and MOH of the three countries during a two-day workshop in Accra, Ghana. The workshop provided an opportunity for MOH and MOF officials to work together and develop recommendations for next steps, culminating in the policy brief report. Eva Mends, Head of Budget Development Unit, Ministry of Finance, Ghana, and Mary Nannono, Permanent Secretary, Ministry of Health, Uganda, joined MacCarthy to address the report findings and discuss specific communication and technical capacities needed to boost health allocations.
Assessment Findings: Strengths and Opportunities in Ghana
"Ministries of Finance should provide feedback to Ministries of Health–show them where the gaps are and help them prioritize their activities better," commented MacCarthy as she discussed the strengths and weaknesses of the MOH and MOF relations in Ghana. MacCarthy argued that relations between the MOF and MOH can be improved by:
- Addressing MOH gaps in technical skills through the recruitment of health economists;
- Involving all government sectors in meetings and negotiations where budget ceilings are established, to improve transparency in this process;
Increasing MOF involvement in MOH budget planning.
MacCarthy shared that the assessment also found the need for increased relations between MOH and MOF and development partners. In order to enhance government support for the health sector, development partners must work to improve the predictability of fund disbursement; align donor goals with country objectives; and provide direct budget support in place of direct program support. "The proliferation of so many donors and so many structures is one of the challenges the system faces," stated MacCarthy. With so many agencies and players involved it is challenging to forecast cash needs and to have a strong accountability structure.
Additionally, the MOH lacks strong analytical skills and is perceived as spreading itself thin by presenting too many activities to the MOF. According to the assessment findings, the MOH in Ghana can increase budget allocations by improving:
- Quality of data generated for planning and budgeting.
- Negotiation and presentation skills.
- Prioritizization and accurate costing of activities.
To improve budgetary support for the health sector, MOHs and MOFs must shift their interactions from a "purely mechanical process to a strategic dialogue," argued MacCarthy. Through increased information sharing, accountability, and collaborative budget planning, the ministries can engage in an effective partnership and improve both the overall health and wealth of the nation.
Health Financing As a Priority in Uganda
"In the case of Uganda, health has been number three in terms of priority and allocation of resources. It is number three after transportation and education," remarked Nannono as she provided a background to health financing in Uganda. According to the Abuja Declaration, of which Uganda is a signatory, 15 percent of annual national expenditures should be allocated towards the health sector. However, as is the case in many African countries including all three in this study, in the last 10 years it has consistently been below 10 percent. This budget shortfall leads to difficult choices and placing increased demands on already over-stretched health systems.
Highlighting results from the Accra workshop, Nannono discussed the need for ministries of health and finance in Uganda to increase communications and improve technical skills within the MOH. According to Nannono:
- MOH needs continuous skill-building and training in budget planning and cash flow management.
- MOH should enhance their oral and written communication with the MOF, with a specific concentration on reports submitted to the MOF.
- MOF should consult with the MOH on a regular basis and explain selected national expenditure priorities.
Nannono described the necessary next steps and emphasized the need to mobilize resources that supports training for the MOH so they may improve budget forecasting, negotiations, and report writing. While increased dialogue was identified as a key action moving forward, Nannono also called for mutual respect between the ministries.
Creating Institutional and Structured Systems for Dialogue
"There's a need for people skills and negotiation skills on both sides," argued Mends. MOF is often perceived as rigid and unsympathetic to the health sectors needs, however, Mends shared that she hopes through increased dialogue this perception will change as sectors come to better appreciate the limitations of the MOF.
"The [budget] process is both a technical and political one," argued Mends. Highlighting the steps of the budget process, Mends noted that though there is several entry points when the MOH can access the MOF, these opportunities are rarely utilized. To bridge this communication gap, Mends stated that the MOF must have a deeper understanding of health issues and make budget allocations through a more interactive process. In addition however, the MOH must also share key information with the MOF so they can appreciate the issues and make informed decisions.
Since the workshop, the MOF in Ghana has made visits to several other ministries to review the budget process and address issues of concern, rather than of waiting for the ministries, many of whom may not come otherwise due to time constraints. The workshop provided an opportunity for MOH and MOF officials to meet with their counterparts–in some cases for the first time–to discuss solutions to common problems. One Ghanaian participant shared, "I was amazed to hear the MOF say that we never argue for higher allocation than the ceiling. Now we will talk to them about increasing this amount." Mends also argued for the following improvements in the current budget process in Ghana:
- Institutionalize a dialogue platform to increase communication and understanding between the ministries.
- Change job description of the finance desk officer so they may also serve as an advocate to the health sector instead of a liaison.
- Increase interpersonal relationship skills.
"Action, action, action," concluded Mends. Underscoring the significance of the workshop and policy paper, Mends stated that the assessment and workshop helped spotlight key areas where the ministries can improve their communication and ability to work together. She called for additional assistance by development partners to help improve technical skills within both ministries, arguing that while additional funds are necessary to improve health services, efficient use of funds is just as important. Moving forward, the findings and recommendations provided in the report are being disseminated throughout Africa so that MOHs and MOFs can incorporate the lessons learned in Ghana, Senegal, and Uganda into their planning.
By Calyn Ostrowski and Zahra Ashraf