External accountability and oversight of the NHSU Effective systems of internal control within a firm and credible budget

EXTERNAL ACCOUNTABILITY AND OVERSIGHT OF THE NHSU

As an autonomous CEA, the NHSU is subordinate and accountable to the CabMin. The law establishing the NHSU gives the MoH and MoF joint authority over key policy decisions governing health financing and NHSU purchasing, including approval of the PMG, tariff, and budget proposals. At the same time, the NHSU is a spending unit secondary to the MoH and as such submits all policy and expenditure proposals and reports to the MoF and the CabMin through the MoH. But the absence of a forum in which the MoH and MoF come together to reach a coherent consensus on health financing strategy and policy before proposals are put to the CabMin impedes the development of a shared strategic vision for health financing. Therefore, an earlier section of this report proposed the creation of an NHSU oversight committee, composed of MoH and MoF representatives and ideally also a representative of the Prime Minister’s Office—for example, the deputy prime minister for regions, who has related responsibilities—to address this.

In addition, the NHSU reports to the PCC, whose membership represents patients and civil society. Law 2168 stipulates that PCC membership should be selected by open, transparent competition, and there are provisions to avoid a conflict of interest of council members. Among the PCC’s responsibilities are monitoring of activities and performance of the NHSU, reviewing reports prepared by the NHSU, and producing and publishing written findings and recommendations. It thus plays an important role in promoting transparency, which helps reinforce that the NHSU’s ultimate accountability is to citizens, as taxpayers and patients. However, the PCC’s role is only an advisory one; it does not have the governance powers or responsibilities of a supervisory board. The PCC’s role in accountability could be strengthened by linking the PCC to formal oversight by the MoH and CabMin and better defining its role. A CabMin order that sets out the details of the PCC’s role, the reports that the NHSU should share with the PCC, and the findings and reports that the PCC should provide to the government could be considered. This order could also establish a formal mechanism by which the PCC can report to the MoH and CabMin, such as via the proposed oversight committee mentioned earlier. The CabMin committee overseeing the NHSU, if established, could periodically meet with the PCC chair and members.

For the NHSU to be held accountable, ideally it also needs to have a set of annual and medium-term performance objectives that are aligned with the government’s health systems’ goals and are realistic given the NHSU’s resources. Reporting by the NHSU currently focuses mainly on the budget and approval of the PMG plus other matters on an ad hoc basis. This means there is no integrated, coherent regular mechanism of ex post accountability by which the NHSU reports to the CabMin on all aspects of performance. Ukraine is currently introducing a new system of performance-based oversight of policy implementation by the CabMin that will strengthen the accountability of the ministries for executing sector strategies. This would create more transparent objectives for the NHSU, integrated within health sector policy, and a framework to report against these objectives through the MoH. Given the early stage of the development of this performance-based system, it would be helpful to pilot the precise mechanism, including relevant aspects of sector policy implementation to be measured and responsibilities for agreeing on and tracking progress on