Contraste de la igualdad de medias para datos apareados

Given the large amount of activities planned, including long-term improvements in the capacity and functioning of the DSMPHDS, it is highly pertinent to know what these activities will cost, as well as the sources for financing these activities. For the purposes of this, financial aspects are split into two main categories: receipts and expenditure. For planning purposes, each can be presented in a variety of ways:

1. Where they are received or incurred (by health facility or level) 2. The health care activity in which they are received or incurred

3. The cost type, for example, capital/recurrent or resource type (e.g. staff, drugs) 4. The identity of the beneficiary or donor

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With the current accounting and financial management system in place, most of both receipts and expenditure items can be tracked by these categories.

5.6.2 Sources of finance

One of the purposes of assessing the sources of finance is to understand where they come from, what influences them, their stability within the year and their expected levels beyond the current year. Also, some financing sources come with conditions, such as the salary block grants, or the basket funds, or from special programmes or research such as NACP or AMMP. Some are generated from activities of the health sector, and can be used in a variety of ways, such as purchasing drugs, staff bonuses, etc. In Chapter 3, Table 3.11 showed the estimated health financing by source for the year 2002, with expenditure by level of the health system for the three Dar es Salaam districts separately. Table 5.6 summarises the average proportion of financing from each source, as well as the conditions for the funds and the expected stability.

The block grant from the Ministry of Health gives the largest single source of income for the DSMPHDS (36%) and a large part of this is on salaries. It is also a reliable source, with increases expected over the years as the health sector is allocated more funds to improve services to fight poverty. The basket funds also provide a significant financial input (19%), also with increases expected over the coming years. Cost sharing raises 10% of the financial resources, but the future of this source depends on future demand levels as well as fee charging policies and the operation of the user fee exemption mechanism. A coherent pricing mechanism is yet to be developed.

The funds and resources received from national programmes are still significant (18%), but these are expected to drop over the coming years as programmes are further integrated into the general health system structure. These funds will be channelled through the Ministry of Health budget and the basket fund. Revenue from the medical supplies and drugs varies between district, from 2.7% in Kinundoni to 9.8% in Temeke, but the future of these funds is not clear. Other sources (pharmacy, AMMP, DUHP, national insurance or community funds) are insignificant, and some of these are declining (DUHP, AMMP), while the future of others is not clear. There may be some increases expected in funds from the national insurance and community funds, depending on the coverage and success of these.

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Table 5.6: Characteristics of different financing sources

Financing source Level (%) Conditions for expenditure

Stability within year Stability over years

Block grant 36% Most on salaries Budget stated at start

of year

Reliable - increasing

Basket funds 19% Stated health

sector priorities

Budget stated at start of year

Reliable – increasing Ministry of

Health

11% Budget stated at start

of year

Reliable – increasing

Cost sharing 10% Recurrent

expenditure

Estimate for income, depends on health service use

Likely to increase if health service use increases (exemptions?) National

programmes

18% Specified activities Budget stated at start

of year

Reliable – increasing, assuming they remain vertical programmes Medical supplies and drugs 3-10% Medical supplies and drugs Estimated budget stated at start of year

Unclear Medical examination <2% General contribution to health facility funds

Estimate for income, depends on health service use

Likely to increase if health service use increases (exemptions?)

Pharmacy <1% Reimburses drug

expenditure

Depends on drug purchases

Unclear

AMMP 1% AMMP research

activities

Budget and activities stated at start of year

AMMP will become integrated into DSS Dar es Salaam Urban Health Project 0% Targeted support, accountable to DUHP office

Budget stated at start of year Phasing out 2002 National Health Insurance Scheme (NHIS) 0% Reimburses expenditure on health service use of insured

Depends on health service use by insured patients (not started yet) Unclear pace of introduction of scheme Community health fund (CHF) 0% Reimburses expenditure on health service use of covered people

Not in use at present Unclear at the present

whether the CHF will be implemented

While in the short term these sources of revenue are relatively fixed, in the longer term it is in the interest of the DSMPHDS to shift its revenue sources not only to efficient mechanisms for raising revenue, but also to mechanisms that do not discourage use of health services by those who are unable to pay. In addition to the amount of funds from each source, the costs of raising the revenue and accounting for the funds must be taken into account (for example, costs of collecting user fees, costs of paperwork for the NHIS). Clearly this an issue that needs to be tackled first and foremost at the national level, but there are some opportunities for improving revenue collection efficiency at the level of Dar es Salaam.

5.6.3 Expenditure

Although some costing studies have been done on the essential health intervention package in Tanzania (EHIP), and one financial study was done under DUHP (Wyss and Petersik

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2000), the most complete cost data for Dar es Salaam are available from routine accounting reports (budget and revenues in the MTEF). As well as sources of revenue, Table 3.11 in Chapter 3 also showed the expenditure by level/structure (MMOH, hospital, health centre, dispensary and community). These data can also be disaggregated by individual health facility as well as by resource type (e.g. personnel, drug, capital items, etc). While certain accounting procedures are essential for the safe transfer and expenditure of funds according to plans, these presentations are often incomplete for the purposes of evaluating whether the optimal amounts of funds are being spent on each health care activity. For example, except what is available from the national programmes, there is limited reliable information available on expenditure by disease or health care activity (e.g. reproductive health care). Expenditure by ‘cost centres’ is now available from the districts, but only a small proportion of the total budget can be accounted for using this approach, and does not include certain cost items such as salaries. Research done by the TEHIP research group has shown that these data can be collected (through expenditure tracking studies), and the use of these data is that % burden of disease can be compared % expenditure on each disease or type of health care to see whether funds are being allocated to and spent on the specified priorities (de Savigny 2000).

So far, the costs have not been estimated for the capacity building and activities required to implement the revised MPHMA (second version). However, based on the separate activities and resource items (salaries, training, equipment, infrastructure, MSD, etc.) as well as the expected changes in patient throughput and the treatment of disease, such costs can be estimated by the districts.

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