Publication: Budget Execution in Health: Concepts, Trends and Policy Issues
Loading...
Files in English
3,417 downloads
Published
2021-11-04
ISSN
Date
2021-11-17
Editor(s)
Abstract
Most countries are committed to the provision of quality health services to all, without risk of financial hardship. Adequate budget provisions are an important, yet insufficient requirement in this pursuit. The budget also needs to be implemented in full and with regard to efficiency and accountability. While this is widely acknowledged, there is no systematic evidence on how well the health budget is implemented and literature remains thin on how budget execution practices relate to health financing functions and service delivery. This report is the first in a series of publications on the topic following an active World Health Organization and World Bank collaboration. It aims to define concepts, characteristics and trends in health sector budget execution. The report first calls for clarity in use of terminology. It helps to differentiate between ‘budget execution rates’ and ‘budget execution practices’. The former refers to the share of the budget being executed. The latter to processes on how well the budget is executed. Both aspects are equally important. Not implementing the budget in full is a lost opportunity, efficiency and accountability concern and undermines the health sector’s ability to deliver services. It also undermines prospects for increased fiscal space going forward. To identify trends and patterns in over and underspending, the report draws on previously unexplored PEFA annex and World Bank BOOST data. This reveals the following: Health budget execution rates are inversely related to levels of income and maturity of PFM systems. Health budget under-execution is particularly pervasive in LMICs where the budget is executed at around 85-90 percent. Some countries have chronic budget execution problems where the budget is executed at a rate below 85 percent across consecutive years. In LMICs, the health budget is systematically implemented at a lower rate than the general government budget. This means, that governments are effectively deprioritizing health during budget implementation. For Sub-Saharan Africa countries in the sample, the average health budget was 6.7 percent of the general government budget. Health spending as a share of general government spending was half a percentage point less at 6.2 percent. In some countries this is much more pronounced, where health is deprioritized by 2-3 percentage points of general government spending during implementation. The health budget was also implemented at a lower rate than the education budget in most countries at an average rate of 4 percentage points. Underspending in some categories often occurs concurrently with overspending on other expenditure items. While the wage and salary budget tend to be implemented in full, this is less so for goods and services or the capital budget. This can leave health workers without the necessary supplies or support infrastructure to provide quality services and invariably lead to inefficiencies.
Link to Data Set
Citation
“Piatti-Funfkirchen, Moritz; Barroy, Helene; Pivodic, Fedja; Margini, Federica. 2021. Budget Execution in Health: Concepts, Trends and Policy Issues. © World Bank. http://hdl.handle.net/10986/36583 License: CC BY 3.0 IGO.”
Digital Object Identifier
Associated URLs
Associated content
Other publications in this report series
Journal
Journal Volume
Journal Issue
Collections
Related items
Showing items related by metadata.
Publication From Stumbling Block to Enabler(Taylor and Francis, 2018-11-06)The way governments manage resources through the budget cycle has important implications for health policy and whether governments achieve societal objectives such as efficiency, equity, quality, and accountability. Studies found a positive association between health service delivery outcomes and good governance of public finance; however, the mechanisms through which public financial management affects service delivery remain underexplored. This article maps the three stages of the budget cycle to common performance criteria used in health service delivery. It applies this approach to experiences in Tanzania and Zambia. The findings point to a number of stumbling blocks, including the lack of flexibility to provide additional resources for unexpected demand for care, misalignment between budgeting and planning, fragmented funding sources, rigid internal controls, insufficient budget provision leading to arrears, and a budget evaluation system that is excessively compliance driven and gives inadequate attention to issues of equity, quality, and efficiency in service delivery.Publication Public Financial Management in the Health Sector(World Bank, Washington, DC, 2020)This study assesses the extent to which public financial management (PFM) in Malawi supports health service provision at the local government level. Using a conceptual framework that links the budget cycle to health service provider management and service delivery goals, the study assesses how the various stages of the budget cycle affect service delivery at health centers and hospitals. Government and faith-based health providers, known as Christian Health Association Malawi (CHAM), are assessed separately. The study provides insights into provider autonomy and flexibility; financial management capacity; payment arrangements; and the performance orientation of budget provisions or purchasing. The results suggest that significant gaps exist, which undermine the service delivery goals of efficiency, quality, equity, and accountability of service provision. A summary of the findings is presented in the report. It provides complimentary guidance as to how PFM systems facilitate provider management and service delivery at district level health centers and hospitals. Findings and recommendations from the study are expected to support decision makers and practitioners with ongoing PFM reforms.Publication Following the Government Playbook? Channeling Development Assistance for Health through Country Systems(World Bank, Washington, DC, 2021-10-21)Development partners (DPs) contribute to a significant share of total health financing, especially in low-income countries, and support the achievement of universal health coverage (UHC). However, if DP support is not well aligned with government systems, it can lead to inefficiencies, such as poor prioritization, fragmentation, and duplication of activities, and inhibit the government’s ability to maintain effective stewardship over sector activities. This note develops a comprehensive interpretation of the term ‘country systems’ in a public financial management (PFM) environment along with a checklist across the budget cycle that can be used to assess whether DPs in a given country are aligned to various PFM aspects. Undertaking an assessment is expected to have the following benefits: to provide a better understanding of the DP financial architecture and contribute to the literature of DP alignment and aid effectiveness; to articulate a clear baseline of DP financing modalities to allow for establishing a logical framework that will help articulate a reform program and strengthen mutual accountability. to foster learning across countries and DPs.Publication Tanzania Health Policy Note(World Bank, Washington, DC, 2021-01-12)This is the second in a series of health policy notes that address critical health finance related questions in Tanzania. They are issued as part of a larger public expenditure review exercise. The audience is government, civil society and the development partner community with the aim to initiate a dialogue around key health finance issues and present recommendations to government. This policy note raises budget execution in health as a problem and discusses reasons behind low rates and the consequences for service delivery.Publication Health Financing in the Republic of Gabon(Washington, DC: World Bank, 2014-09-30)This is a review of the health financing situation in the Republic of Gabon. The book reviews the situation in the country under the lens of the principles of health financing: revenue mobilization for health, risk pooling, and purchasing services. The book also estimates the fiscal space in health that is, looking at options that can increase resources for health within a macroeconomic and fiscal context. Universal health coverage has been defined as a situation where all people who need health services (prevention, promotion, treatment, rehabilitation, and palliative) receive them, without undue financial hardship. Universal health coverage consists of three inter-related components: (i) the full spectrum of quality health services according to need; (ii) financial protection from direct payment for health services when consumed; and (iii) coverage for the entire population. Because of Gabon's commitment to universal health coverage, certain segments are calling for additional resources for this sector. As a result, the country is grappling with the following: (i) how are resources being spent, (ii) is there room for a more efficient allocation of current resources, or (iii) is there an urgent need to mobilize additional resources to meet the goal. This book attempts to diagnose the situation and offer additional information to enlighten and fuel the debate. The book has six chapters: chapter one gives background and objectives. Chapter two provides an overview of the country s health status and service use patterns. Chapter three provides an overview of health financing systems and outputs. Chapter four provides an overview of the national health insurance and social security (caisse nationale d'assurance maladie et de garantie sociale) (CNAMGS). Chapter five provides fiscal space analysis for health. Finally, chapter six provides the reform issues and policy options in health financing.
Users also downloaded
Showing related downloaded files
Publication Africa’s Pulse, No. 32, October 2025: Pathways to Job Creation in Africa(Washington, DC: World Bank, 2025-10-07)Economic growth in Sub-Saharan Africa is expected to increase from 3.5 percent in 2024 to 3.8 percent in 2025 and accelerate further to an annual average rate of 4.4 percent in 2026–27. Improved terms of trade are helping to stabilize local currencies, but real income per capita is only set to rise slightly, leaving extreme poverty largely unchallenged. By 2050, the region is projected to have over 620 million more working-age individuals. This demographic shift calls for innovative and transformative approaches to job creation, as current growth doesn't significantly lead to wage employment. To tackle these issues, foundational infrastructure and skills, a favorable business environment, and good governance are essential. Addressing the constraints to the private sector development opens the door for productive sectors of the economy to grow and generate quality employment, including but not limited to agribusiness, tourism, and healthcare, among others. With the right approach, Sub-Saharan Africa can establish a vibrant job market. This would help meet the needs of its growing labor force.Publication Digital Africa(Washington, DC: World Bank, 2023-03-13)All African countries need better and more jobs for their growing populations. "Digital Africa: Technological Transformation for Jobs" shows that broader use of productivity-enhancing, digital technologies by enterprises and households is imperative to generate such jobs, including for lower-skilled people. At the same time, it can support not only countries’ short-term objective of postpandemic economic recovery but also their vision of economic transformation with more inclusive growth. These outcomes are not automatic, however. Mobile internet availability has increased throughout the continent in recent years, but Africa’s uptake gap is the highest in the world. Areas with at least 3G mobile internet service now cover 84 percent of Africa’s population, but only 22 percent uses such services. And the average African business lags in the use of smartphones and computers as well as more sophisticated digital technologies that catalyze further productivity gains. Two issues explain the usage gap: affordability of these new technologies and willingness to use them. For the 40 percent of Africans below the extreme poverty line, mobile data plans alone would cost one-third of their incomes—in addition to the price of access devices, apps, and electricity. Data plans for small- and medium-size businesses are also more expensive than in other regions. Moreover, shortcomings in the quality of internet services—and in the supply of attractive, skills-appropriate apps that promote entrepreneurship and raise earnings—dampen people’s willingness to use them. For those countries already using these technologies, the development payoffs are significant. New empirical studies for this report add to the rapidly growing evidence that mobile internet availability directly raises enterprise productivity, increases jobs, and reduces poverty throughout Africa. To realize these and other benefits more widely, Africa’s countries must implement complementary and mutually reinforcing policies to strengthen both consumers’ ability to pay and willingness to use digital technologies. These interventions must prioritize productive use to generate large numbers of inclusive jobs in a region poised to benefit from a massive, youthful workforce—one projected to become the world’s largest by the end of this century.Publication The Global Findex Database 2025: Connectivity and Financial Inclusion in the Digital Economy(Washington, DC: World Bank, 2025-07-16)The Global Findex 2025 reveals how mobile technology is equipping more adults around the world to own and use financial accounts to save formally, access credit, make and receive digital payments, and pursue opportunities. Including the inaugural Global Findex Digital Connectivity Tracker, this fifth edition of Global Findex presents new insights on the interactions among mobile phone ownership, internet use, and financial inclusion. The Global Findex is the world’s most comprehensive database on digital and financial inclusion. It is also the only global source of comparable demand-side data, allowing cross-country analysis of how adults access and use mobile phones, the internet, and financial accounts to reach digital information and resources, save, borrow, make payments, and manage their financial health. Data for the Global Findex 2025 were collected from nationally representative surveys of about 145,000 adults in 141 economies. The latest edition follows the 2011, 2014, 2017, and 2021 editions and includes new series measuring mobile phone ownership and internet use, digital safety, and frequency of transactions using financial services. The Global Findex 2025 is an indispensable resource for policy makers in the fields of digital connectivity and financial inclusion, as well as for practitioners, researchers, and development professionals.Publication The World Bank Group Annual Report 2025(Washington, DC: World Bank, 2025-10-09)The World Bank Group Annual Report 2025 presents on World Bank Group activities in fiscal 2025. The Annual Report is prepared by the Executive Directors of ICSID, IFC, MIGA, and the World Bank (IBRD/IDA) in accordance with the by-laws of the institutions. The President of the World Bank Group and Chairman of the Board of Executive Directors submit the Annual Report, together with the accompanying administrative budgets and audited financial statements, to the Board of Governors.Publication Business Ready 2024(Washington, DC: World Bank, 2024-10-03)Business Ready (B-READY) is a new World Bank Group corporate flagship report that evaluates the business and investment climate worldwide. It replaces and improves upon the Doing Business project. B-READY provides a comprehensive data set and description of the factors that strengthen the private sector, not only by advancing the interests of individual firms but also by elevating the interests of workers, consumers, potential new enterprises, and the natural environment. This 2024 report introduces a new analytical framework that benchmarks economies based on three pillars: Regulatory Framework, Public Services, and Operational Efficiency. The analysis centers on 10 topics essential for private sector development that correspond to various stages of the life cycle of a firm. The report also offers insights into three cross-cutting themes that are relevant for modern economies: digital adoption, environmental sustainability, and gender. B-READY draws on a robust data collection process that includes specially tailored expert questionnaires and firm-level surveys. The 2024 report, which covers 50 economies, serves as the first in a series that will expand in geographical coverage and refine its methodology over time, supporting reform advocacy, policy guidance, and further analysis and research.