IMPROVING EFFECTIVE COVERAGE IN HEALTH
decisions on human resource management, including hiring, firing, provision of incentive payments, and taking corrective action. On the use of funds, there are significant variations and the level of autonomy may differ by expenditure type. For example, salaries may be paid centrally, drugs procured by a central medical store, and investment spending managed by the district administration. This would only leave autonomy over other nonwage recurrent spending. The degree to which facilities should have autonomy over various spending items will vary by country context, but it is an important factor to consider. Facilities should be limited in purchasing items that fall outside the remits of their level of care (for example, a primary care provider should not have the autonomy to procure a magnetic resonance imaging scanner). Tenet B: Health facilities require adequate financial management capacity It is important that facilities can manage funds prudently and carefully account for and report on the use of funds to ensure accountability and inform decision making. Although it is preferred that facilities are paid against outputs, this does not relieve them of the need to account for and report on spending against inputs. Ledgers on revenue and expenditures must be maintained carefully and audited periodically. Further, due process is required for the procurement of products and services to ensure value for money. These aspects are akin to basic business management. As financial management capacity at the facility level grows, ministries of finance are likely to be more willing to extend greater degrees of autonomy to facilities. As such, this is likely a sequential reform process over the medium term. Emerging technologies can be explored to minimize capacity-building needs. For example, it may not be desirable to hire accountants at every facility. Instead, payments made through smartcards or mobile money that automatically captures spending categories would greatly reduce the financial management burden on facility managers who in turn can focus on patients instead. Tenet C: A unified payment system supports facility management Health facilities often draw on multiple sources for payment. These may include input-based budget provisions from the government budget, revenue from user fees, payment from insurance funds, and support from various development partners. These multiple sources fragment the 228
